Provider Demographics
NPI:1972769321
Name:GOSSEN, DOUGLAS (RPH)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:GOSSEN
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 1:2051 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-8801
Mailing Address - Country:US
Mailing Address - Phone:815-467-1254
Mailing Address - Fax:
Practice Address - Street 1:2051 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-8801
Practice Address - Country:US
Practice Address - Phone:815-467-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist