Provider Demographics
NPI:1669185419
Name:BATES, GARY EDWARD JR
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:EDWARD
Last Name:BATES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2927
Mailing Address - Country:US
Mailing Address - Phone:231-941-5332
Mailing Address - Fax:
Practice Address - Street 1:1104 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2927
Practice Address - Country:US
Practice Address - Phone:231-941-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303043529183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician