Provider Demographics
NPI:1710059217
Name:GORE, AUSTIN E (RPH)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:E
Last Name:GORE
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 1:880 HICKORY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-7362
Mailing Address - Country:US
Mailing Address - Phone:706-855-1915
Mailing Address - Fax:706-855-1456
Practice Address - Street 1:3708 EXECUTIVE CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-0956
Practice Address - Country:US
Practice Address - Phone:706-855-1915
Practice Address - Fax:706-855-1456
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5166860001Medicare NSC