Provider Demographics
NPI:1942580303
Name:MONDELL, GARY (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MONDELL
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 1:540 BOB-O-LINK DRIVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3854
Mailing Address - Country:US
Mailing Address - Phone:208-529-5395
Mailing Address - Fax:208-528-6563
Practice Address - Street 1:1901 S 2500 E
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-5710
Practice Address - Country:US
Practice Address - Phone:208-524-1616
Practice Address - Fax:208-528-6563
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP40821835P0018X
ORRPH-00063991835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist