Provider Demographics
NPI:1811228265
Name:SELF, GARY JONATHAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JONATHAN
Last Name:SELF
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 1:4800 HIGHWAY 365
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-7403
Mailing Address - Country:US
Mailing Address - Phone:409-722-4066
Mailing Address - Fax:409-722-4588
Practice Address - Street 1:4800 HIGHWAY 365
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-7403
Practice Address - Country:US
Practice Address - Phone:409-722-4066
Practice Address - Fax:409-722-4588
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist