Provider Demographics
NPI:1841286952
Name:LEWIS, GARY LEE
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:LEWIS
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 1:1941 NEVADA 23
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-7008
Mailing Address - Country:US
Mailing Address - Phone:870-887-5857
Mailing Address - Fax:870-887-2113
Practice Address - Street 1:1430 W 1ST ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-3339
Practice Address - Country:US
Practice Address - Phone:870-887-2717
Practice Address - Fax:870-887-2113
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR05910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR05910OtherPHARMACIST LICENSE