Provider Demographics
NPI:1417940578
Name:PULLEN, GARY KEVIN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:KEVIN
Last Name:PULLEN
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 1:2250 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7552
Mailing Address - Country:US
Mailing Address - Phone:208-528-7979
Mailing Address - Fax:208-512-2238
Practice Address - Street 1:2250 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7552
Practice Address - Country:US
Practice Address - Phone:208-528-7979
Practice Address - Fax:208-512-2238
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4336183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy