Provider Demographics
NPI:1568709400
Name:KOONTZ, GARRY ODELL
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:ODELL
Last Name:KOONTZ
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 1:17179 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-7291
Mailing Address - Country:US
Mailing Address - Phone:941-426-8577
Mailing Address - Fax:
Practice Address - Street 1:17179 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-7291
Practice Address - Country:US
Practice Address - Phone:941-426-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0025245183500000X
NC07806183500000X
GARPH015444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist