Provider Demographics
NPI:1932423282
Name:WILLISON, GARY WAYNE (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:WAYNE
Last Name:WILLISON
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 1:1388 CALKINS RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-2521
Mailing Address - Country:US
Mailing Address - Phone:585-334-8323
Mailing Address - Fax:
Practice Address - Street 1:2665 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14467-9370
Practice Address - Country:US
Practice Address - Phone:585-359-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032064-I183500000X
PARP442542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist