Provider Demographics
NPI:1003101668
Name:GORSKE, CHARLES ALLEN (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALLEN
Last Name:GORSKE
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 1:134 FANNA ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5816
Mailing Address - Country:US
Mailing Address - Phone:920-922-7715
Mailing Address - Fax:920-921-6759
Practice Address - Street 1:485 N ROLLING MEADOWS DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-9784
Practice Address - Country:US
Practice Address - Phone:920-921-6759
Practice Address - Fax:920-921-6759
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIR-6566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist