Provider Demographics
NPI: | 1013523760 |
---|---|
Name: | SWANSON, GAGE GREGORY (PHARMD, RPH) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | GAGE |
Middle Name: | GREGORY |
Last Name: | SWANSON |
Suffix: | |
Gender: | M |
Credentials: | PHARMD, RPH |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1402 S RIDGE ROAD |
Mailing Address - Street 2: | |
Mailing Address - City: | WICHITA |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 67209 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 316-945-7455 |
Mailing Address - Fax: | 316-945-7457 |
Practice Address - Street 1: | 1402 S RIDGE ROAD |
Practice Address - Street 2: | |
Practice Address - City: | WICHITA |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67209 |
Practice Address - Country: | US |
Practice Address - Phone: | 316-945-7455 |
Practice Address - Fax: | 316-945-7457 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2020-09-18 |
Last Update Date: | 2020-09-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KS | 1-13640 | 1835N1003X, 1835P1200X, 1835P1300X, 1835G0303X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1835G0303X | Pharmacy Service Providers | Pharmacist | Geriatric |
No | 1835N1003X | Pharmacy Service Providers | Pharmacist | Nutrition Support |
No | 1835P1200X | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No | 1835P1300X | Pharmacy Service Providers | Pharmacist | Psychiatric |