Provider Demographics
NPI:1104042381
Name:CUNNINGHAM, GARY LANE (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:LANE
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1562
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-1562
Mailing Address - Country:US
Mailing Address - Phone:304-682-4586
Mailing Address - Fax:
Practice Address - Street 1:22 LARRY JOE HARLESS DR.
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621
Practice Address - Country:US
Practice Address - Phone:304-664-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist