Provider Demographics
NPI:1154726719
Name:ALLEN, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26603 72ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-6273
Mailing Address - Country:US
Mailing Address - Phone:360-629-5520
Mailing Address - Fax:360-629-5538
Practice Address - Street 1:26603 72ND AVE NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6273
Practice Address - Country:US
Practice Address - Phone:360-629-5520
Practice Address - Fax:360-629-5538
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist