Provider Demographics
NPI:1639170277
Name:BLAIR, GARY WESLEY (DPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:WESLEY
Last Name:BLAIR
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 WESTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-5729
Mailing Address - Country:US
Mailing Address - Phone:972-412-1665
Mailing Address - Fax:972-412-1699
Practice Address - Street 1:1301 YOUNG ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202-5433
Practice Address - Country:US
Practice Address - Phone:214-767-4438
Practice Address - Fax:214-767-0323
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9496183500000X
TX43017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist