Healthcare Provider Details

I. General information

NPI: 1669094629
Provider Name (Legal Business Name): LEE GARY NEAL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 E VILLA MARIA RD STE 120
BRYAN TX
77802-2585
US

IV. Provider business mailing address

2215 E VILLA MARIA RD STE 120
BRYAN TX
77802-2585
US

V. Phone/Fax

Practice location:
  • Phone: 979-977-0193
  • Fax: 979-776-0427
Mailing address:
  • Phone: 979-977-0193
  • Fax: 979-776-0427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number56471
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: