Provider Demographics
NPI:1447615687
Name:FONTAINE, GABRIEL VICTOR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:VICTOR
Last Name:FONTAINE
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 1:8030 S 1400 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6609
Mailing Address - Country:US
Mailing Address - Phone:207-212-9170
Mailing Address - Fax:
Practice Address - Street 1:8030 S 1400 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6609
Practice Address - Country:US
Practice Address - Phone:207-212-9170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8327130-17011835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy