Provider Demographics
NPI:1790126662
Name:SOULE, GARY G
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:G
Last Name:SOULE
Suffix:
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 1:1611 PACE ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-3052
Mailing Address - Country:US
Mailing Address - Phone:303-776-7590
Mailing Address - Fax:
Practice Address - Street 1:1611 PACE ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-3052
Practice Address - Country:US
Practice Address - Phone:303-776-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO183500000XMedicare PIN