Provider Demographics
NPI:1073857686
Name:DURICA, GAVRILO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GAVRILO
Middle Name:
Last Name:DURICA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 S WHT MTN RD APT 622
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7334
Mailing Address - Country:US
Mailing Address - Phone:716-951-9508
Mailing Address - Fax:
Practice Address - Street 1:900 W DEUCE OF CLUBS
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-6214
Practice Address - Country:US
Practice Address - Phone:928-532-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS019569OtherAZ PHARMACIST LICENSE
AZ3191OtherAZ IMMUNIZATION CERTIFICATE