Provider Demographics
NPI:1093189557
Name:IVEY, GARY (PD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:IVEY
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 S PLEASANT CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1345
Mailing Address - Country:US
Mailing Address - Phone:479-621-0629
Mailing Address - Fax:479-621-8126
Practice Address - Street 1:4208 S PLEASANT CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1345
Practice Address - Country:US
Practice Address - Phone:479-621-0629
Practice Address - Fax:479-621-8126
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist