Provider Demographics
NPI:1508127614
Name:GUSTAVSON, ALAN CARL (RPH)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:CARL
Last Name:GUSTAVSON
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 1:211 E BANNISTER ST STE E
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-1372
Mailing Address - Country:US
Mailing Address - Phone:269-685-9807
Mailing Address - Fax:269-685-8536
Practice Address - Street 1:6430 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2016
Practice Address - Country:US
Practice Address - Phone:269-375-5369
Practice Address - Fax:269-372-8920
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist