Provider Demographics
NPI:1437422250
Name:GARDNER, DYLAN AVERY (PHARMD)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:AVERY
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S HILL RD
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-8410
Mailing Address - Country:US
Mailing Address - Phone:509-836-2192
Mailing Address - Fax:509-837-7036
Practice Address - Street 1:110 S HILL RD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8410
Practice Address - Country:US
Practice Address - Phone:509-836-2192
Practice Address - Fax:509-837-7036
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00040651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH 00040651OtherSTATE PHARMACIST LICENSE