Provider Demographics
NPI:1326336439
Name:ERICKSON, GUS T (RPH)
Entity Type:Individual
Prefix:MR
First Name:GUS
Middle Name:T
Last Name:ERICKSON
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 1:3450 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-1501
Mailing Address - Country:US
Mailing Address - Phone:641-423-1325
Mailing Address - Fax:641-423-1325
Practice Address - Street 1:3450 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1501
Practice Address - Country:US
Practice Address - Phone:641-423-1325
Practice Address - Fax:641-423-1325
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12893183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist