MEDICARE: DAN YAW GORDON PHARMACIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	21294021001	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21294021001	OTHER	MI	PHARMACIST

General Provider Information

NPI Number	:	1477276582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAN YAW GORDON PHARMACIST

Provider Business Mailing Address
First Line	:	1115 RUNAWAY BAY DR APT 2D
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917-8729
Country	:	US
Telephone Number	:	682-240-1660
Fax Number	:

Provider Business Practice Location Address
First Line	:	812 E SAGINAW HWY
Second Line	:
City	:	GRAND LEDGE
State	:	MI
Zip	:	48837-8410
Country	:	US
Telephone Number	:	517-627-1240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2022
Last Update Date	:	09/22/2022

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