Provider Demographics
NPI:1275685141
Name:ALWAN, GARY L (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:ALWAN
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 1:311 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-5638
Mailing Address - Country:US
Mailing Address - Phone:309-676-6333
Mailing Address - Fax:309-676-1928
Practice Address - Street 1:311 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-5638
Practice Address - Country:US
Practice Address - Phone:309-676-6333
Practice Address - Fax:309-676-1928
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist