Healthcare Provider Details

I. General information

NPI: 1073627212
Provider Name (Legal Business Name): DELBERT GARY MARTIN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6822 EAST 1000 SOUTH
FORT DUCHESNE UT
84026
US

IV. Provider business mailing address

6822 EAST 1000 SOUTH
FORT DUCHESNE UT
84026
US

V. Phone/Fax

Practice location:
  • Phone: 435-725-6874
  • Fax:
Mailing address:
  • Phone: 435-725-6874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number341687-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: