MEDICARE: GARY E POULSON RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	27044	TX

General Provider Information

NPI Number	:	1427647478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY E POULSON RPH

Provider Business Mailing Address
First Line	:	1424 NORTH ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4037
Country	:	US
Telephone Number	:	936-569-9596
Fax Number	:

Provider Business Practice Location Address
First Line	:	1424 NORTH ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4037
Country	:	US
Telephone Number	:	936-569-9596
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2021
Last Update Date	:	01/14/2021

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