Provider Demographics
NPI:1679833024
Name:METELAK, GARY PETER (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:PETER
Last Name:METELAK
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 1:1210 FREMONTIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-1212
Mailing Address - Country:US
Mailing Address - Phone:805-525-5884
Mailing Address - Fax:
Practice Address - Street 1:147 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2809
Practice Address - Country:US
Practice Address - Phone:805-652-5068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist