Provider Demographics
NPI:1710693163
Name:LANGE, GAVIN CHARLES (PHARMACY TECHNICIAN)
Entity Type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:CHARLES
Last Name:LANGE
Suffix:
Gender:M
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-7787
Mailing Address - Country:US
Mailing Address - Phone:410-254-2055
Mailing Address - Fax:
Practice Address - Street 1:6701 HARFORD RD
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-7721
Practice Address - Country:US
Practice Address - Phone:410-254-2055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT27627156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMD10272062356OtherLICENSE