Provider Demographics
NPI:1114641941
Name:GAGNON, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:GAGNON
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 1:31 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02892-1964
Mailing Address - Country:US
Mailing Address - Phone:401-742-2225
Mailing Address - Fax:
Practice Address - Street 1:31 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:WEST KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02892-1964
Practice Address - Country:US
Practice Address - Phone:401-742-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIR3642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist