Provider Demographics
NPI:1881976694
Name:GOURLEY, ADAM KEITH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:KEITH
Last Name:GOURLEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5032 N 500 E
Mailing Address - Street 2:
Mailing Address - City:ROLLING PRAIRIE
Mailing Address - State:IN
Mailing Address - Zip Code:46371-9734
Mailing Address - Country:US
Mailing Address - Phone:219-363-5795
Mailing Address - Fax:
Practice Address - Street 1:1710 W JOHN BEERS RD
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9409
Practice Address - Country:US
Practice Address - Phone:269-429-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037769183500000X
IN26022330A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist