Provider Demographics
NPI:1821309758
Name:WOODSON, GARY TIBBETT (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:TIBBETT
Last Name:WOODSON
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 1:22 LOZEAU LANE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:MT
Mailing Address - Zip Code:59872
Mailing Address - Country:US
Mailing Address - Phone:406-822-3859
Mailing Address - Fax:
Practice Address - Street 1:22 LOZEAU LN
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:MT
Practice Address - Zip Code:59872-9622
Practice Address - Country:US
Practice Address - Phone:406-822-3859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3871183500000X
OR4579183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist