Provider Demographics
NPI:1972926582
Name:GUSTAFSON, NICHOLAS DEAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:DEAN
Last Name:GUSTAFSON
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 1:1525 E 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-1670
Mailing Address - Country:US
Mailing Address - Phone:816-836-9918
Mailing Address - Fax:816-836-9919
Practice Address - Street 1:1525 E 23RD ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-1670
Practice Address - Country:US
Practice Address - Phone:816-836-9918
Practice Address - Fax:816-836-9919
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005001462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist