Provider Demographics
NPI:1831643782
Name:GARDNER, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ST LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8310
Mailing Address - Country:US
Mailing Address - Phone:419-455-7147
Mailing Address - Fax:
Practice Address - Street 1:45 ST LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8310
Practice Address - Country:US
Practice Address - Phone:419-455-7147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH031205341835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH449927OtherNABP
OH03120534OtherOHIO PHARMACIST LICENSE