Provider Demographics
NPI:1689234528
Name:GORRELL, JAKE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:GORRELL
Suffix:
Gender:M
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:MO
Mailing Address - Zip Code:65785-0189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:MO
Practice Address - Zip Code:65785-7617
Practice Address - Country:US
Practice Address - Phone:417-276-3128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019019411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist