Provider Demographics
NPI:1659882439
Name:PRUETT, GARY RYAN (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RYAN
Last Name:PRUETT
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 1:1085 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1955
Mailing Address - Country:US
Mailing Address - Phone:573-705-1299
Mailing Address - Fax:
Practice Address - Street 1:705 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-705-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001024808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist