Provider Demographics
NPI:1225336720
Name:OGORK, EBOB E (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EBOB
Middle Name:E
Last Name:OGORK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 MORINDA DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2727
Mailing Address - Country:US
Mailing Address - Phone:770-489-7431
Mailing Address - Fax:
Practice Address - Street 1:4442 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2724
Practice Address - Country:US
Practice Address - Phone:770-943-0592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist