Provider Demographics
NPI:1851920326
Name:PAYTON, GARY (R PH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PAYTON
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4948 TARRY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7567
Mailing Address - Country:US
Mailing Address - Phone:678-895-8905
Mailing Address - Fax:
Practice Address - Street 1:4948 TARRY GLEN DR
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7567
Practice Address - Country:US
Practice Address - Phone:678-895-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA015397OtherBOARD OF PHARMACY