Provider Demographics
NPI:1588267892
Name:PACK, GABRIELLE (PHARMD)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-2140
Mailing Address - Country:US
Mailing Address - Phone:435-228-1003
Mailing Address - Fax:
Practice Address - Street 1:188 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2140
Practice Address - Country:US
Practice Address - Phone:435-228-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9076263-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist