Provider Demographics
NPI:1487362331
Name:GAUDREAULT, OLIVIA MARIE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MARIE
Last Name:GAUDREAULT
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 1:2744 E BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1232
Mailing Address - Country:US
Mailing Address - Phone:443-223-0365
Mailing Address - Fax:
Practice Address - Street 1:9270 ALL SAINTS RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-1702
Practice Address - Country:US
Practice Address - Phone:301-725-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28937183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist