MEDICARE: MR. GARY WESLEY BLAIR D.PH.

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	9496	OK
2	183500000X	Pharmacist	43017	TX

General Provider Information

NPI Number	:	1639170277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY WESLEY BLAIR D.PH.

Provider Business Mailing Address
First Line	:	3401 WESTWOOD CIR
Second Line	:
City	:	ROWLETT
State	:	TX
Zip	:	75088-5729
Country	:	US
Telephone Number	:	972-412-1665
Fax Number	:	972-412-1699

Provider Business Practice Location Address
First Line	:	1301 YOUNG ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75202-5433
Country	:	US
Telephone Number	:	214-767-4438
Fax Number	:	214-767-0323

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

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	07/08/2007

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