Provider Demographics
NPI:1104961515
Name:SIMMONS, GARY MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:MICHAEL
Last Name:SIMMONS
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 1:909 W PINE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4958
Mailing Address - Country:US
Mailing Address - Phone:573-785-0984
Mailing Address - Fax:573-785-2257
Practice Address - Street 1:909 W PINE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4958
Practice Address - Country:US
Practice Address - Phone:573-785-0984
Practice Address - Fax:573-785-2257
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist