Provider Demographics
NPI:1861613671
Name:FUGATE, GARDNER (RPH)
Entity type:Individual
Prefix:MR
First Name:GARDNER
Middle Name:
Last Name:FUGATE
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 1:3510 CASS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220
Mailing Address - Country:US
Mailing Address - Phone:505-885-2165
Mailing Address - Fax:505-887-8300
Practice Address - Street 1:808 N CANAL
Practice Address - Street 2:ALBERTSONS PHARMACY
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220
Practice Address - Country:US
Practice Address - Phone:505-885-2165
Practice Address - Fax:505-887-8300
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist