Provider Demographics
NPI:1699507723
Name:THOMAS, GWYNETH
Entity type:Individual
Prefix:
First Name:GWYNETH
Middle Name:
Last Name:THOMAS
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 1:372 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIMBERVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22853-9522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:372 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TIMBERVILLE
Practice Address - State:VA
Practice Address - Zip Code:22853-9522
Practice Address - Country:US
Practice Address - Phone:540-896-6407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202222247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist