Provider Demographics
NPI:1477276582
Name:GORDON, DAN YAW (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:YAW
Last Name:GORDON
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 1:1115 RUNAWAY BAY DR APT 2D
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8729
Mailing Address - Country:US
Mailing Address - Phone:682-240-1660
Mailing Address - Fax:
Practice Address - Street 1:812 E SAGINAW HWY
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8410
Practice Address - Country:US
Practice Address - Phone:517-627-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI21294021001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI21294021001OtherPHARMACIST