Provider Demographics
NPI:1275687972
Name:DAMM, GARY (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:DAMM
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 1:1101 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2714
Mailing Address - Country:US
Mailing Address - Phone:316-788-6669
Mailing Address - Fax:316-788-3570
Practice Address - Street 1:1101 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2714
Practice Address - Country:US
Practice Address - Phone:316-788-6669
Practice Address - Fax:316-788-3570
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-07934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100437990AMedicaid
KS100437990AMedicaid