Provider Demographics
NPI:1245315696
Name:VANDIVER, GAYLAND GENE (RPH)
Entity type:Individual
Prefix:MR
First Name:GAYLAND
Middle Name:GENE
Last Name:VANDIVER
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 1:101 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77327-4414
Mailing Address - Country:US
Mailing Address - Phone:281-592-0491
Mailing Address - Fax:281-592-0459
Practice Address - Street 1:101 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4414
Practice Address - Country:US
Practice Address - Phone:281-592-0491
Practice Address - Fax:281-592-0459
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21096183500000X
NM3846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist