Provider Demographics
NPI:1932270170
Name:PHILLIPS, GARY (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PHILLIPS
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 1:2811 W DOUBLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-9215
Mailing Address - Country:US
Mailing Address - Phone:229-894-5904
Mailing Address - Fax:810-821-8150
Practice Address - Street 1:400 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2359
Practice Address - Country:US
Practice Address - Phone:229-432-1141
Practice Address - Fax:229-439-0305
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0012453183500000X
FLPS16448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist