Provider Demographics
NPI:1922309749
Name:GORE, CHARLES
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:GORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6775 W 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2453
Mailing Address - Country:US
Mailing Address - Phone:303-466-8449
Mailing Address - Fax:
Practice Address - Street 1:6775 W 120TH AVE
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2453
Practice Address - Country:US
Practice Address - Phone:303-466-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13526183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist