Provider Demographics
NPI:1265594964
Name:GORMAN, WILLIAM CARTER (RPH)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CARTER
Last Name:GORMAN
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:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-0821
Mailing Address - Country:US
Mailing Address - Phone:770-963-2438
Mailing Address - Fax:770-963-0166
Practice Address - Street 1:470 N CLAYTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-4872
Practice Address - Country:US
Practice Address - Phone:770-963-2438
Practice Address - Fax:770-963-0166
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00032227AMedicaid
GA00032227AMedicaid