Basic Information
| Provider Information | |||||||||
| NPI: | 1255947602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GABRIELSON | ||||||||
| FirstName: | DAVIS | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | PHARM. D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 12TH AVE S | ||||||||
| Address2: | |||||||||
| City: | SARTELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563774710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3204290242 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3601 2ND ST S | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563013762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3203459821 | ||||||||
| FaxNumber: | 3203459811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 118814 | MN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.