Provider Demographics
NPI:1285115105
Name:GILLINGHAM, JARED MASON
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:MASON
Last Name:GILLINGHAM
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 1:10947 W ROYAL PALM RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-1900
Mailing Address - Country:US
Mailing Address - Phone:608-475-1507
Mailing Address - Fax:
Practice Address - Street 1:19505 N SUNRISE BLVD # SURPRISE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4739
Practice Address - Country:US
Practice Address - Phone:623-556-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist