Provider Demographics
NPI:1215226634
Name:GAUM, ALAN LESLIE
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:LESLIE
Last Name:GAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 N RUSTLING RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-2722
Mailing Address - Country:US
Mailing Address - Phone:304-744-4504
Mailing Address - Fax:
Practice Address - Street 1:10404 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:MARMET
Practice Address - State:WV
Practice Address - Zip Code:25315-1916
Practice Address - Country:US
Practice Address - Phone:304-949-2838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist