Provider Demographics
NPI:1033728175
Name:NEPHEW, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:NEPHEW
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 1:1937 COUNTRY CIR S
Mailing Address - Street 2:
Mailing Address - City:NAPPANEE
Mailing Address - State:IN
Mailing Address - Zip Code:46550-8969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2824 ELKHART RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1014
Practice Address - Country:US
Practice Address - Phone:574-537-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024001A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26024001AOtherINDIANA BOARD OF PHARMACY