Provider Demographics
NPI:1679573042
Name:MEDLEY, GERALD G I
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:G
Last Name:MEDLEY
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 CALLE MARINA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4315
Mailing Address - Country:US
Mailing Address - Phone:949-361-4939
Mailing Address - Fax:949-496-0489
Practice Address - Street 1:665 CAMINO DE LOS MARES
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2840
Practice Address - Country:US
Practice Address - Phone:949-496-0123
Practice Address - Fax:949-496-0489
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist