Provider Demographics
NPI:1104349059
Name:EFAW, DEVON JANEAN
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:JANEAN
Last Name:EFAW
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 1:4674 HUSKY HWY
Mailing Address - Street 2:
Mailing Address - City:MANNINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26582-7150
Mailing Address - Country:US
Mailing Address - Phone:304-365-2418
Mailing Address - Fax:
Practice Address - Street 1:208 S PIKE ST
Practice Address - Street 2:
Practice Address - City:SHINNSTON
Practice Address - State:WV
Practice Address - Zip Code:26431-1122
Practice Address - Country:US
Practice Address - Phone:304-592-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0010195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist