Provider Demographics
NPI:1649267493
Name:DEBLAQUIERE, GARY ALFRED (RPH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ALFRED
Last Name:DEBLAQUIERE
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-0458
Mailing Address - Country:US
Mailing Address - Phone:208-448-1633
Mailing Address - Fax:208-448-1728
Practice Address - Street 1:1222 ALBENI HWY
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-9393
Practice Address - Country:US
Practice Address - Phone:208-448-1633
Practice Address - Fax:208-448-1728
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP4094OtherPHARMACY LIC