Provider Demographics
NPI:1750569943
Name:NANSON, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:NANSON
Suffix:
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 1:2910 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2910 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1976
Practice Address - Country:US
Practice Address - Phone:810-987-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-10
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist