Provider Demographics
NPI:1225300890
Name:SURESCH, GARY WAYNE
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:SURESCH
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 1:4077 N HATCHET CIR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3448
Mailing Address - Country:US
Mailing Address - Phone:352-746-7162
Mailing Address - Fax:
Practice Address - Street 1:310 NE US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4235
Practice Address - Country:US
Practice Address - Phone:352-563-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS16513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist