Provider Demographics
NPI:1932476355
Name:SIMMONS, GWEN MARGRAVE (RPH)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MARGRAVE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 234
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748
Mailing Address - Country:US
Mailing Address - Phone:865-882-1675
Mailing Address - Fax:
Practice Address - Street 1:373 S ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6741
Practice Address - Country:US
Practice Address - Phone:865-483-9825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003738183500000X
GARPH020800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist