Provider Demographics
NPI:1629352836
Name:MCCRAE, GORDON RALPH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:RALPH
Last Name:MCCRAE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4416
Mailing Address - Country:US
Mailing Address - Phone:208-233-2382
Mailing Address - Fax:208-233-2648
Practice Address - Street 1:905 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4416
Practice Address - Country:US
Practice Address - Phone:208-233-2382
Practice Address - Fax:208-233-2648
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5103183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist