Provider Demographics
NPI:1063894020
Name:GILMORE, RICKY (RPH)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:GILMORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7707 94TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1955
Mailing Address - Country:US
Mailing Address - Phone:262-597-1037
Mailing Address - Fax:262-597-1028
Practice Address - Street 1:7707 94TH AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1955
Practice Address - Country:US
Practice Address - Phone:262-597-1037
Practice Address - Fax:262-597-1028
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14616-40183500000X
IL051-036052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist