Provider Demographics
NPI:1659833069
Name:SHORTLEY, GARY LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LYNN
Last Name:SHORTLEY
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 1:2802 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-4708
Mailing Address - Country:US
Mailing Address - Phone:641-753-3204
Mailing Address - Fax:641-753-0057
Practice Address - Street 1:2802 S CENTER ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-4708
Practice Address - Country:US
Practice Address - Phone:641-753-3204
Practice Address - Fax:641-753-0057
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist