Healthcare Provider Details

I. General information

NPI: 1497208870
Provider Name (Legal Business Name): GAVIN DULEY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W 4TH AVE
CANEY KS
67333-1462
US

IV. Provider business mailing address

208 W 4TH AVE
CANEY KS
67333-1462
US

V. Phone/Fax

Practice location:
  • Phone: 620-879-5822
  • Fax: 620-879-2721
Mailing address:
  • Phone: 620-879-5822
  • Fax: 620-879-2721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-15260
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number22565
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: