Provider Demographics
NPI:1477120046
Name:GAYETSKY, MICHAEL JAMES
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:GAYETSKY
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 1:667 EASTLAND AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4503
Mailing Address - Country:US
Mailing Address - Phone:330-841-4030
Mailing Address - Fax:
Practice Address - Street 1:667 EASTLAND AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4503
Practice Address - Country:US
Practice Address - Phone:330-841-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03212715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist