Provider Demographics
NPI:1811396906
Name:GIFFORD, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GIFFORD
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 1:7707 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2100
Mailing Address - Country:US
Mailing Address - Phone:316-651-2703
Mailing Address - Fax:
Practice Address - Street 1:7707 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2100
Practice Address - Country:US
Practice Address - Phone:316-651-2703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist