Provider Demographics
NPI:1972268126
Name:GAGE, MALLY (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:MALLY
Middle Name:
Last Name:GAGE
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 W EVA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-3241
Mailing Address - Country:US
Mailing Address - Phone:520-979-4566
Mailing Address - Fax:
Practice Address - Street 1:18460 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-1108
Practice Address - Country:US
Practice Address - Phone:602-993-5781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS025283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist