Provider Demographics
NPI:1679700264
Name:CLERICI, GARY W (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:CLERICI
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 1:102 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:PA
Mailing Address - Zip Code:16323-2313
Mailing Address - Country:US
Mailing Address - Phone:814-437-9115
Mailing Address - Fax:
Practice Address - Street 1:102 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-2313
Practice Address - Country:US
Practice Address - Phone:814-437-9115
Practice Address - Fax:814-437-1263
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3336C0003X
PARP029971L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA156646Medicare PIN