Provider Demographics
NPI:1669511960
Name:MULLIGAN, GARY EDWARD (R PH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EDWARD
Last Name:MULLIGAN
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-1206
Mailing Address - Country:US
Mailing Address - Phone:814-237-9094
Mailing Address - Fax:
Practice Address - Street 1:724 S ATHERTON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4628
Practice Address - Country:US
Practice Address - Phone:814-238-2712
Practice Address - Fax:814-238-0480
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP027461L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP027461LOtherPHARMACY LICENSE