Provider Demographics
NPI:1174679187
Name:PRIESKORN, GARY MICHAEL (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:PRIESKORN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12026 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49272-9705
Mailing Address - Country:US
Mailing Address - Phone:517-589-9822
Mailing Address - Fax:
Practice Address - Street 1:826 W BELLEVUE ST
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251-9302
Practice Address - Country:US
Practice Address - Phone:517-589-8291
Practice Address - Fax:517-589-5819
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020373183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist