Healthcare Provider Details

I. General information

NPI: 1144390071
Provider Name (Legal Business Name): GARY WAKEMAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAWS AVE
UKIAH CA
95482-6540
US

IV. Provider business mailing address

333 LAWS AVE
UKIAH CA
95482-6540
US

V. Phone/Fax

Practice location:
  • Phone: 707-468-1010
  • Fax: 707-468-0174
Mailing address:
  • Phone: 707-468-1010
  • Fax: 707-468-0174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH27263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: