Provider Demographics
NPI:1144761461
Name:SIMMONS, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58135 RANDOLPHS DR
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-7430
Mailing Address - Country:US
Mailing Address - Phone:985-515-3102
Mailing Address - Fax:
Practice Address - Street 1:103 MEDICINE WAY
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542
Practice Address - Country:US
Practice Address - Phone:928-475-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist