Provider Demographics
NPI:1538491501
Name:CARLBERG, DAVID GORDON (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GORDON
Last Name:CARLBERG
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 1:10 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6609
Mailing Address - Country:US
Mailing Address - Phone:716-661-9230
Mailing Address - Fax:
Practice Address - Street 1:10 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-1948
Practice Address - Country:US
Practice Address - Phone:716-661-9230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02927815Medicaid
NY02927815Medicaid
NY6029830001Medicare NSC