Healthcare Provider Details

I. General information

NPI: 1679253934
Provider Name (Legal Business Name): NICOLE LAREA GORSUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S MAIN ST
CHARLESTON MO
63834-1644
US

IV. Provider business mailing address

406 S MAIN ST
CHARLESTON MO
63834-1644
US

V. Phone/Fax

Practice location:
  • Phone: 573-683-3307
  • Fax:
Mailing address:
  • Phone: 573-683-3307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2023028919
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: