Provider Demographics
NPI:1932824570
Name:WEATHERWAX, GENTRY MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GENTRY
Middle Name:MARIE
Last Name:WEATHERWAX
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 HORRY RD
Mailing Address - Street 2:
Mailing Address - City:AYNOR
Mailing Address - State:SC
Mailing Address - Zip Code:29511-4946
Mailing Address - Country:US
Mailing Address - Phone:843-742-4899
Mailing Address - Fax:
Practice Address - Street 1:1415 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6012
Practice Address - Country:US
Practice Address - Phone:843-238-5159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist