Provider Demographics
NPI:1093803041
Name:GUSTAFSON, DEB (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DEB
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19045 WALDEN DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1172
Mailing Address - Country:US
Mailing Address - Phone:616-842-7614
Mailing Address - Fax:
Practice Address - Street 1:961 SPRING ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3278
Practice Address - Country:US
Practice Address - Phone:231-722-2861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024218183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302024218OtherRPH LICENSE