Provider Demographics
NPI:1780248583
Name:GUNSALLUS, WADE C (PHARMD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:C
Last Name:GUNSALLUS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9601 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-2155
Mailing Address - Country:US
Mailing Address - Phone:303-453-4964
Mailing Address - Fax:
Practice Address - Street 1:9601 GRANT ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-2155
Practice Address - Country:US
Practice Address - Phone:303-453-4964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist