Provider Demographics
NPI:1205907664
Name:BANDY, GARY J (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:J
Last Name:BANDY
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 1:905 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62951-1219
Mailing Address - Country:US
Mailing Address - Phone:618-983-8272
Mailing Address - Fax:618-983-7871
Practice Address - Street 1:905 GRAND AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951-1219
Practice Address - Country:US
Practice Address - Phone:618-983-8272
Practice Address - Fax:618-983-7871
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371243554001Medicaid
IL371243554001Medicaid