Provider Demographics
NPI:1790396315
Name:GOURGUE, TAMARAH
Entity Type:Individual
Prefix:DR
First Name:TAMARAH
Middle Name:
Last Name:GOURGUE
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 1:235 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01949-2445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:MA
Practice Address - Zip Code:01949-2445
Practice Address - Country:US
Practice Address - Phone:978-762-8522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH239439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PH239439OtherPHARMACIST