Provider Demographics
NPI:1700158128
Name:GORMAN, MICHAEL H (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:H
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:N26W22519 OAKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1081
Mailing Address - Country:US
Mailing Address - Phone:262-542-5306
Mailing Address - Fax:
Practice Address - Street 1:N83W15701 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3042
Practice Address - Country:US
Practice Address - Phone:262-251-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8717-40183500000X
AZS016578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist