=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295321131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY JAMES BUTZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2020
-----------------------------------------------------
Last Update Date | 12/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 KINSLEY DR
-----------------------------------------------------
City | BRODHEADSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18322-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-402-0786
-----------------------------------------------------
Fax | 570-992-1668
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 272 SWITZGABEL DR
-----------------------------------------------------
City | BRODHEADSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18322-7122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-992-5288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP027982L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------