Provider Demographics
NPI:1992412068
Name:BROOKS, GARY WAYNE
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:BROOKS
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 1:3 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:AL
Mailing Address - Zip Code:35040-9581
Mailing Address - Country:US
Mailing Address - Phone:205-612-9449
Mailing Address - Fax:
Practice Address - Street 1:701 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-3603
Practice Address - Country:US
Practice Address - Phone:334-365-7015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist