Provider Demographics
NPI:1710196597
Name:GOURLEY, HEATHER HALL (RPH)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:HALL
Last Name:GOURLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-3369
Mailing Address - Country:US
Mailing Address - Phone:912-537-3049
Mailing Address - Fax:912-537-3040
Practice Address - Street 1:306 W 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-3369
Practice Address - Country:US
Practice Address - Phone:912-537-3049
Practice Address - Fax:912-537-3040
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist