Provider Demographics
NPI:1356434435
Name:GLOUDEMAN, MARK WILLIAM (PHARMD, CDE)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:GLOUDEMAN
Suffix:
Gender:M
Credentials:PHARMD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 QUALITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-1006
Mailing Address - Country:US
Mailing Address - Phone:707-624-2167
Mailing Address - Fax:
Practice Address - Street 1:1 QUALITY DRIVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-1006
Practice Address - Country:US
Practice Address - Phone:707-624-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist