Provider Demographics
NPI:1033529441
Name:WILLERSHAUSEN, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WILLERSHAUSEN
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 1:205 S RANGE RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2605
Mailing Address - Country:US
Mailing Address - Phone:810-388-9633
Mailing Address - Fax:810-388-9665
Practice Address - Street 1:205 S RANGE RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2605
Practice Address - Country:US
Practice Address - Phone:810-388-9633
Practice Address - Fax:810-388-9665
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020269721835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy