Provider Demographics
NPI:1891086708
Name:HUDDLESTON, GARY MOORE (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:MOORE
Last Name:HUDDLESTON
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 1:305 N WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-2300
Mailing Address - Country:US
Mailing Address - Phone:903-796-2866
Mailing Address - Fax:903-796-2867
Practice Address - Street 1:305 N WILLIAM ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-2300
Practice Address - Country:US
Practice Address - Phone:903-796-2866
Practice Address - Fax:903-796-2867
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist