Healthcare Provider Details

I. General information

NPI: 1639170277
Provider Name (Legal Business Name): GARY WESLEY BLAIR D.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 YOUNG ST
DALLAS TX
75202-5433
US

IV. Provider business mailing address

3401 WESTWOOD CIR
ROWLETT TX
75088-5729
US

V. Phone/Fax

Practice location:
  • Phone: 214-767-4438
  • Fax: 214-767-0323
Mailing address:
  • Phone: 972-412-1665
  • Fax: 972-412-1699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9496
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number43017
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: