Provider Demographics
NPI:1083213235
Name:GARDNER, RYAN JOSEPH (RPH)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JOSEPH
Last Name:GARDNER
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 1:1717 N SHAWANO ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-9365
Mailing Address - Country:US
Mailing Address - Phone:920-982-7906
Mailing Address - Fax:920-982-7915
Practice Address - Street 1:1717 N SHAWANO ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-9365
Practice Address - Country:US
Practice Address - Phone:920-982-7906
Practice Address - Fax:920-982-7915
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19428-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist