Provider Demographics
NPI:1154440477
Name:KIRK, GARY EDWARD (DPH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:EDWARD
Last Name:KIRK
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 FREMONT DR
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2405
Mailing Address - Country:US
Mailing Address - Phone:918-577-2101
Mailing Address - Fax:
Practice Address - Street 1:1703 FREMONT DR
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2405
Practice Address - Country:US
Practice Address - Phone:918-577-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0022602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22602Medicaid