Provider Demographics
NPI:1144864646
Name:STIVALI, GARY CHARLES
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:CHARLES
Last Name:STIVALI
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 1:18 TERN CV
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-5027
Mailing Address - Country:US
Mailing Address - Phone:727-453-1790
Mailing Address - Fax:
Practice Address - Street 1:1803 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-2100
Practice Address - Country:US
Practice Address - Phone:727-441-6819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22272183500000X
GARPH014773183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist