Provider Demographics
NPI:1578899902
Name:SOLOMON, GARY RICHARD (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RICHARD
Last Name:SOLOMON
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 1:25725 DEMETER WAY
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-4630
Mailing Address - Country:US
Mailing Address - Phone:949-683-2114
Mailing Address - Fax:949-770-3000
Practice Address - Street 1:25725 DEMETER WAY
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-4630
Practice Address - Country:US
Practice Address - Phone:949-683-2114
Practice Address - Fax:949-770-3000
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30412Medicaid