Healthcare Provider Details

I. General information

NPI: 1306827845
Provider Name (Legal Business Name): JANE F GORMAN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 NOYAC RD
SOUTHAMPTON NY
11968-1440
US

IV. Provider business mailing address

219 NOYAC RD
SOUTHAMPTON NY
11968-1440
US

V. Phone/Fax

Practice location:
  • Phone: 631-726-8245
  • Fax: 631-726-8805
Mailing address:
  • Phone: 631-726-8245
  • Fax: 631-726-8805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0436411
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: