Provider Demographics
NPI:1043425721
Name:DENNIS, GARY L (R PH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:DENNIS
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 PROFESSIONAL CENTER DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2168
Mailing Address - Country:US
Mailing Address - Phone:707-588-8894
Mailing Address - Fax:707-588-8908
Practice Address - Street 1:170 PROFESSIONAL CENTER DR
Practice Address - Street 2:SUITE C
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2168
Practice Address - Country:US
Practice Address - Phone:707-588-8894
Practice Address - Fax:707-588-8908
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 27812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist