Provider Demographics
NPI:1386782829
Name:LEVINE, GARY L (RPH, CDM)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:LEVINE
Suffix:
Gender:M
Credentials:RPH, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 CUMMINS PKWY
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-1133
Mailing Address - Country:US
Mailing Address - Phone:515-277-7448
Mailing Address - Fax:
Practice Address - Street 1:4100 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-3533
Practice Address - Country:US
Practice Address - Phone:515-633-8606
Practice Address - Fax:515-866-6309
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist