Provider Demographics
NPI:1780225789
Name:GUSTAFSON, JOHN DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:GUSTAFSON
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 1:125 E BESTOR DR
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1972
Mailing Address - Country:US
Mailing Address - Phone:309-944-5675
Mailing Address - Fax:309-944-4510
Practice Address - Street 1:125 E BESTOR DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1972
Practice Address - Country:US
Practice Address - Phone:309-944-5675
Practice Address - Fax:309-944-4510
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033526183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist