Provider Demographics
NPI:1295777571
Name:CERETTO, GARY (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:CERETTO
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 1:2700 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5624
Mailing Address - Country:US
Mailing Address - Phone:618-288-7474
Mailing Address - Fax:618-288-1860
Practice Address - Street 1:2700 N CENTER ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5624
Practice Address - Country:US
Practice Address - Phone:618-288-7474
Practice Address - Fax:618-288-1860
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL260047130001Medicaid
BM8204365OtherDEA