Provider Demographics
NPI:1184741233
Name:ELLETT, GARY W (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:ELLETT
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 1:12606 K DRIVE
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:IA
Mailing Address - Zip Code:50220
Mailing Address - Country:US
Mailing Address - Phone:515-438-3280
Mailing Address - Fax:
Practice Address - Street 1:1251 334TH STREET
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:IA
Practice Address - Zip Code:50276
Practice Address - Country:US
Practice Address - Phone:515-438-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13198OtherPHARMACIST LICENSE