Provider Demographics
NPI:1720363872
Name:MYATT, GENE ALLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GENE
Middle Name:ALLEN
Last Name:MYATT
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 1:3275 STATE ROAD 32 E
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8564
Mailing Address - Country:US
Mailing Address - Phone:317-896-9019
Mailing Address - Fax:317-896-9372
Practice Address - Street 1:3275 STATE ROAD 32 E
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8564
Practice Address - Country:US
Practice Address - Phone:317-896-9019
Practice Address - Fax:317-896-9372
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013842A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist