Provider Demographics
NPI:1063061869
Name:GENTRY, MARIA MARGARET
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:MARGARET
Last Name:GENTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2544
Mailing Address - Country:US
Mailing Address - Phone:513-378-9081
Mailing Address - Fax:
Practice Address - Street 1:1250 PATROL RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-8670
Practice Address - Country:US
Practice Address - Phone:513-378-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027558A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26027558AOtherREGISTERED PHARMACIST
KY019661OtherREGISTERED PHARMACIST