Provider Demographics
NPI:1801171194
Name:SMITH, GARY ROBERT
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:ROBERT
Last Name:SMITH
Suffix:
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 1:4420 NW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3101
Mailing Address - Country:US
Mailing Address - Phone:772-232-9289
Mailing Address - Fax:772-232-9778
Practice Address - Street 1:4420 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-3101
Practice Address - Country:US
Practice Address - Phone:772-232-9289
Practice Address - Fax:772-232-9778
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist