Provider Demographics
NPI:1477827343
Name:MAYNARD, GARY (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MAYNARD
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 1:100 NW 20TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1029
Mailing Address - Country:US
Mailing Address - Phone:503-226-7179
Mailing Address - Fax:
Practice Address - Street 1:100 NW 20TH PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1029
Practice Address - Country:US
Practice Address - Phone:503-226-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06990183500000X
ORRPH-00069901835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist