Provider Demographics
NPI:1841600244
Name:OSBURN, GARY (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:OSBURN
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 1:4605 BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7204
Mailing Address - Country:US
Mailing Address - Phone:810-982-0708
Mailing Address - Fax:
Practice Address - Street 1:4775 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3405
Practice Address - Country:US
Practice Address - Phone:810-385-2133
Practice Address - Fax:810-385-2165
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020236221835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$OtherSSN