Provider Demographics
NPI:1598363988
Name:O'GORMAN, HEATHER ALLISON
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ALLISON
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12231 E DOVE HILL DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-9583
Mailing Address - Country:US
Mailing Address - Phone:785-280-3735
Mailing Address - Fax:
Practice Address - Street 1:509 STATE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-1107
Practice Address - Country:US
Practice Address - Phone:316-775-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist