Healthcare Provider Details

I. General information

NPI: 1417940578
Provider Name (Legal Business Name): GARY KEVIN PULLEN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 CORONADO ST
IDAHO FALLS ID
83404-7552
US

IV. Provider business mailing address

2250 CORONADO ST
IDAHO FALLS ID
83404-7552
US

V. Phone/Fax

Practice location:
  • Phone: 208-528-7979
  • Fax: 208-512-2238
Mailing address:
  • Phone: 208-528-7979
  • Fax: 208-512-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4336
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberP4336
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: