Provider Demographics
NPI:1891039467
Name:GWENDOLYN JEFFRO
Entity Type:Organization
Organization Name:GWENDOLYN JEFFRO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISPENDING
Authorized Official - Prefix:MISS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JEFFRO
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:414-967-7006
Mailing Address - Street 1:3707 N RICHARDS ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1673
Mailing Address - Country:US
Mailing Address - Phone:414-967-7006
Mailing Address - Fax:414-967-7020
Practice Address - Street 1:3707 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1673
Practice Address - Country:US
Practice Address - Phone:414-967-7006
Practice Address - Fax:414-967-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32807-31332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site