Provider Demographics
NPI:1326648916
Name:OPDENHOFF, GARY LOUIS
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LOUIS
Last Name:OPDENHOFF
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 1:1507 PELLINORE ST
Mailing Address - Street 2:
Mailing Address - City:BORGER
Mailing Address - State:TX
Mailing Address - Zip Code:79007-6342
Mailing Address - Country:US
Mailing Address - Phone:806-674-7973
Mailing Address - Fax:
Practice Address - Street 1:1501 ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:BORGER
Practice Address - State:TX
Practice Address - Zip Code:79007-4408
Practice Address - Country:US
Practice Address - Phone:806-274-7243
Practice Address - Fax:806-274-3557
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist