Provider Demographics
NPI:1144511999
Name:GILG, ROGER
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:GILG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1089 N WISNER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3143
Mailing Address - Country:US
Mailing Address - Phone:517-782-0574
Mailing Address - Fax:517-787-5592
Practice Address - Street 1:1089 N WISNER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3143
Practice Address - Country:US
Practice Address - Phone:517-782-0574
Practice Address - Fax:517-787-5592
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI183500000X-PHARMACISOtherADD TAXONOMY