Provider Demographics
NPI:1003193368
Name:GORENCE, MICHAEL JAMES (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:GORENCE
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 1:9728 WINTER GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3809
Mailing Address - Country:US
Mailing Address - Phone:619-938-0069
Mailing Address - Fax:619-938-9565
Practice Address - Street 1:9728 WINTER GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3809
Practice Address - Country:US
Practice Address - Phone:619-938-0069
Practice Address - Fax:619-938-9565
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60684183500000X
WAPH00065853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist