Provider Demographics
NPI:1154860955
Name:GORGOL, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GORGOL
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 1:6620 GRANT WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9316
Mailing Address - Country:US
Mailing Address - Phone:610-437-8850
Mailing Address - Fax:610-437-8852
Practice Address - Street 1:6620 GRANT WAY
Practice Address - Street 2:SUITE B
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-9316
Practice Address - Country:US
Practice Address - Phone:610-437-8850
Practice Address - Fax:610-437-8852
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PWRP030047L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist