Provider Demographics
NPI:1205424645
Name:GUSTAFSON, LYNSEY N (PHARMD)
Entity type:Individual
Prefix:
First Name:LYNSEY
Middle Name:N
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8847 PENROSE LN APT 408
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-8193
Mailing Address - Country:US
Mailing Address - Phone:913-972-8510
Mailing Address - Fax:
Practice Address - Street 1:8501 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-3220
Practice Address - Country:US
Practice Address - Phone:913-894-2079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-105874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist