Healthcare Provider Details

I. General information

NPI: 1144761461
Provider Name (Legal Business Name): GARY SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MEDICINE WAY
PERIDOT AZ
85542
US

IV. Provider business mailing address

58135 RANDOLPHS DR
PLAQUEMINE LA
70764-7430
US

V. Phone/Fax

Practice location:
  • Phone: 928-475-1300
  • Fax:
Mailing address:
  • Phone: 985-515-3102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13029
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: