Provider Demographics
NPI:1588649867
Name:GORTAT, DAVID LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LEE
Last Name:GORTAT
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 1:2727 HIGHWAY AVE
Mailing Address - Street 2:PHARMACY
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1615
Mailing Address - Country:US
Mailing Address - Phone:219-923-2520
Mailing Address - Fax:219-923-2701
Practice Address - Street 1:2727 HIGHWAY AVE
Practice Address - Street 2:PHARMACY
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1615
Practice Address - Country:US
Practice Address - Phone:219-923-2520
Practice Address - Fax:219-923-2701
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013102A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26013102AOtherPHARMACIST LICENSE