Provider Demographics
NPI:1225565112
Name:GURGA, MARK WILLIAM JR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:GURGA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2309
Mailing Address - Country:US
Mailing Address - Phone:203-747-0239
Mailing Address - Fax:
Practice Address - Street 1:326 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-2508
Practice Address - Country:US
Practice Address - Phone:860-621-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0013063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist