Provider Demographics
NPI:1255947602
Name:GABRIELSON, DAVIS LYN (PHARM D)
Entity type:Individual
Prefix:
First Name:DAVIS
Middle Name:LYN
Last Name:GABRIELSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4710
Mailing Address - Country:US
Mailing Address - Phone:320-429-0242
Mailing Address - Fax:
Practice Address - Street 1:3601 2ND ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3762
Practice Address - Country:US
Practice Address - Phone:320-345-9821
Practice Address - Fax:320-345-9811
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118814183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist