Provider Demographics
NPI:1962519397
Name:HENDERSON, GARY LEE (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:HENDERSON
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 1:2146 FRONTIER DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-9038
Mailing Address - Country:US
Mailing Address - Phone:915-564-7942
Mailing Address - Fax:
Practice Address - Street 1:5001 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-4210
Practice Address - Country:US
Practice Address - Phone:915-564-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist