Provider Demographics
NPI:1104193184
Name:SUTHERBY, GARY BRIAN JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:BRIAN
Last Name:SUTHERBY
Suffix:JR
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 1:1122 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360
Mailing Address - Country:US
Mailing Address - Phone:336-476-8190
Mailing Address - Fax:
Practice Address - Street 1:1122 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-5175
Practice Address - Country:US
Practice Address - Phone:336-476-8190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0295872Medicaid