Provider Demographics
NPI:1265754782
Name:GNATYUK, OLGA (RPH)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:GNATYUK
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 1:1993 DICKERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-2795
Mailing Address - Country:US
Mailing Address - Phone:704-225-9010
Mailing Address - Fax:704-225-7179
Practice Address - Street 1:1993 DICKERSON BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2795
Practice Address - Country:US
Practice Address - Phone:704-225-9010
Practice Address - Fax:704-225-7179
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0905539Medicaid