Provider Demographics
NPI:1891243705
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 1:6495 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-5202
Mailing Address - Country:US
Mailing Address - Phone:618-687-3478
Mailing Address - Fax:618-687-3547
Practice Address - Street 1:6495 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-5202
Practice Address - Country:US
Practice Address - Phone:618-687-3478
Practice Address - Fax:618-687-3547
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051039834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1306863683OtherNPI