Provider Demographics
NPI:1891928222
Name:BROWN, GARY IVAN (RPH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:IVAN
Last Name:BROWN
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 1:292 MAIN STREET
Mailing Address - Street 2:PO BOX 338
Mailing Address - City:GILBERT
Mailing Address - State:WV
Mailing Address - Zip Code:25621-0338
Mailing Address - Country:US
Mailing Address - Phone:304-664-9800
Mailing Address - Fax:304-664-2358
Practice Address - Street 1:292 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621
Practice Address - Country:US
Practice Address - Phone:304-664-9800
Practice Address - Fax:304-664-2358
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004185183500000X
VA0202007074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202007074OtherSTATE OF VA BOARD OF PHARMACY LICENSE
WVRP0004185OtherSTATE OF WV BOARD OF PHARMACY LICENSE