Provider Demographics
NPI:1144427014
Name:INGRAM, GARY L (RPH, CPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:INGRAM
Suffix:
Gender:M
Credentials:RPH, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 SW 49TH LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-6510
Mailing Address - Country:US
Mailing Address - Phone:239-541-1839
Mailing Address - Fax:
Practice Address - Street 1:404 SW 49TH LN
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6510
Practice Address - Country:US
Practice Address - Phone:239-699-3814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPU5926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist