Basic Information
| Provider Information | |||||||||
| NPI: | 1891039467 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GWENDOLYN JEFFRO | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3707 N RICHARDS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149677006 | ||||||||
| FaxNumber: | 4149677020 | ||||||||
| Practice Location | |||||||||
| Address1: | 3707 N RICHARDS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149677006 | ||||||||
| FaxNumber: | 4149677020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2012 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | JEFFRO | ||||||||
| AuthorizedOfficialFirstName: | GWENDOLYN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DISPENDING | ||||||||
| AuthorizedOfficialTelephone: | 4149677006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LPN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 32807-31 | WI | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.