MEDICARE: GARRY ODELL KOONTZ

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	PS0025245	FL
2	183500000X	Pharmacist	07806	NC
3	183500000X	Pharmacist	RPH015444	GA

General Provider Information

NPI Number	:	1568709400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARRY ODELL KOONTZ

Provider Business Mailing Address
First Line	:	17179 TAMIAMI TRL
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-7291
Country	:	US
Telephone Number	:	941-426-8577
Fax Number	:

Provider Business Practice Location Address
First Line	:	17179 TAMIAMI TRL
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-7291
Country	:	US
Telephone Number	:	941-426-8577
Fax Number	:

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

Provider Enumeration Date	:	01/11/2013
Last Update Date	:	01/11/2013

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