Provider Demographics
NPI:1780716597
Name:GARDNER, DAVID NICHOLSON (RPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:NICHOLSON
Last Name:GARDNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-1644
Mailing Address - Country:US
Mailing Address - Phone:660-258-2122
Mailing Address - Fax:660-258-7338
Practice Address - Street 1:206 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-1644
Practice Address - Country:US
Practice Address - Phone:660-258-2122
Practice Address - Fax:660-258-7338
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0422911835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy