MEDICARE: MR. GARY WAYNE SELL RPH,CDE

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	1835N1003X	Nutrition Support Pharmacist	07614	CT

General Provider Information

NPI Number	:	1710974399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY WAYNE SELL RPH,CDE

Provider Business Mailing Address
First Line	:	333 MANLEY HEIGHTS RD
Second Line	:
City	:	ORANGE
State	:	CT
Zip	:	06477-3028
Country	:	US
Telephone Number	:	203-795-4862
Fax Number	:	203-795-1924

Provider Business Practice Location Address
First Line	:	333 MANLEY HEIGHTS RD
Second Line	:
City	:	ORANGE
State	:	CT
Zip	:	06477-3028
Country	:	US
Telephone Number	:	203-795-4862
Fax Number	:	203-795-1924

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

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	07/08/2007

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