Provider Demographics
NPI:1417303041
Name:GORGAN, CIPRIAN (RPH)
Entity Type:Individual
Prefix:
First Name:CIPRIAN
Middle Name:
Last Name:GORGAN
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 1:312 E LE MOYNE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60164-2607
Mailing Address - Country:US
Mailing Address - Phone:312-714-2973
Mailing Address - Fax:
Practice Address - Street 1:312 E LE MOYNE AVE
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2607
Practice Address - Country:US
Practice Address - Phone:312-714-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291548183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist