Provider Demographics
NPI:1457637415
Name:HAKES, GARY DEAN
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DEAN
Last Name:HAKES
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 1:9017 CRYSTAL BROOK DR
Mailing Address - Street 2:
Mailing Address - City:APISON
Mailing Address - State:TN
Mailing Address - Zip Code:37302-7518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 BROAD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37409-1026
Practice Address - Country:US
Practice Address - Phone:423-267-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25214183500000X
AZ5458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist