Provider Demographics
NPI:1003186073
Name:GAST, ELLSWORTH P
Entity Type:Individual
Prefix:
First Name:ELLSWORTH
Middle Name:P
Last Name:GAST
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 1:2843 NEWBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-5214
Mailing Address - Country:US
Mailing Address - Phone:920-465-1936
Mailing Address - Fax:
Practice Address - Street 1:1995 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3920
Practice Address - Country:US
Practice Address - Phone:920-465-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7587-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist