Provider Demographics
NPI:1942871942
Name:CARLSON, GERALD THOMAS JR
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:THOMAS
Last Name:CARLSON
Suffix:JR
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 1:6013 WYNDHAM WAY
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5790
Mailing Address - Country:US
Mailing Address - Phone:765-702-9452
Mailing Address - Fax:
Practice Address - Street 1:410 PILGRIM BLVD
Practice Address - Street 2:
Practice Address - City:HARTFORD CITY
Practice Address - State:IN
Practice Address - Zip Code:47348-1382
Practice Address - Country:US
Practice Address - Phone:765-331-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016905A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist