Provider Demographics
NPI:1134443385
Name:GARROR, GWENDOLYN COLEMAN (RPH)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:COLEMAN
Last Name:GARROR
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:132 FAIRMOUNT DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-2050
Mailing Address - Country:US
Mailing Address - Phone:601-988-1710
Mailing Address - Fax:601-988-1711
Practice Address - Street 1:132 FAIRMOUNT DRIVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-988-1710
Practice Address - Fax:601-988-1711
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051923-1183500000X
MSE-7907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1134443385OtherIMMUNIZATIONS