Provider Demographics
NPI:1851817332
Name:GOMES, JUDITH
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:GOMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 WADE HAMPTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2014 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1037
Practice Address - Country:US
Practice Address - Phone:864-214-8703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist