Provider Demographics
NPI:1154384683
Name:GORTAT, MARY KATHLEEN (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:GORTAT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8937 LIABLE RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2265
Mailing Address - Country:US
Mailing Address - Phone:219-972-3506
Mailing Address - Fax:
Practice Address - Street 1:2727 HIGHWAY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1615
Practice Address - Country:US
Practice Address - Phone:219-972-3506
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013351A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist