Provider Demographics
NPI:1386723864
Name:PHILLIPS, GARY JOE (RPH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JOE
Last Name:PHILLIPS
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 1:400 OLD SMITHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-8464
Mailing Address - Country:US
Mailing Address - Phone:919-581-4681
Mailing Address - Fax:919-581-4689
Practice Address - Street 1:400 OLD SMITHFIELD RD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-8464
Practice Address - Country:US
Practice Address - Phone:919-581-4681
Practice Address - Fax:919-581-4689
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8276OtherNCBOP