Provider Demographics
NPI:1740881960
Name:GAULTNEY, MICHAEL BERT (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BERT
Last Name:GAULTNEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 COMMONWEALTH DR
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1169
Mailing Address - Country:US
Mailing Address - Phone:276-228-2621
Mailing Address - Fax:276-228-5290
Practice Address - Street 1:345 COMMONWEALTH DR
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1169
Practice Address - Country:US
Practice Address - Phone:276-228-2621
Practice Address - Fax:276-228-5290
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202006969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist