Healthcare Provider Details

I. General information

NPI: 1659860484
Provider Name (Legal Business Name): HALA GOURGY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26502 TOWNE CENTRE DR
FOOTHILL RANCH CA
92610-3448
US

IV. Provider business mailing address

26502 TOWNE CENTRE DR
FOOTHILL RANCH CA
92610-3448
US

V. Phone/Fax

Practice location:
  • Phone: 949-837-0504
  • Fax:
Mailing address:
  • Phone: 949-837-0504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number46717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: