Provider Demographics
NPI:1497061352
Name:GUSTIN, DANIEL JAMES (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JAMES
Last Name:GUSTIN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 LOMBARDI AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304
Mailing Address - Country:US
Mailing Address - Phone:920-499-6004
Mailing Address - Fax:920-499-7959
Practice Address - Street 1:1109 LOMBARDI AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304
Practice Address - Country:US
Practice Address - Phone:920-499-6004
Practice Address - Fax:920-499-7959
Is Sole Proprietor?:No
Enumeration Date:2010-08-28
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15396-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist