Provider Demographics
NPI:1740677988
Name:GUSTAFSON, RHONDA
Entity type:Individual
Prefix:
First Name:RHONDA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOWRIE
Mailing Address - State:IA
Mailing Address - Zip Code:50543-7438
Mailing Address - Country:US
Mailing Address - Phone:515-352-3876
Mailing Address - Fax:515-352-3878
Practice Address - Street 1:1800 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOWRIE
Practice Address - State:IA
Practice Address - Zip Code:50543-7438
Practice Address - Country:US
Practice Address - Phone:515-352-3876
Practice Address - Fax:515-352-3878
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16771183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist