Provider Demographics
NPI:1467590646
Name:GURLEY, FRED C (RPH)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:C
Last Name:GURLEY
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 1:864 STOREY PORTER RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-2628
Mailing Address - Country:US
Mailing Address - Phone:706-367-9391
Mailing Address - Fax:706-367-2283
Practice Address - Street 1:86 N PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-1084
Practice Address - Country:US
Practice Address - Phone:706-367-5252
Practice Address - Fax:706-367-2283
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00025495AMedicaid
GA00025495AMedicaid