Provider Demographics
NPI:1629014832
Name:SMITH, GARY O (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:O
Last Name:SMITH
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:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-0470
Mailing Address - Country:US
Mailing Address - Phone:360-794-7234
Mailing Address - Fax:
Practice Address - Street 1:17788 147TH ST SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1030
Practice Address - Country:US
Practice Address - Phone:360-794-7351
Practice Address - Fax:360-794-5751
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist