Provider Demographics
NPI:1366729188
Name:MARSHALL, GARY (DPH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 S JAMES CAMPBELL BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5193
Mailing Address - Country:US
Mailing Address - Phone:631-380-0599
Mailing Address - Fax:931-380-3039
Practice Address - Street 1:1202 S JAMES CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5193
Practice Address - Country:US
Practice Address - Phone:631-380-0599
Practice Address - Fax:931-380-3039
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN8089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist