Provider Demographics
NPI:1386981330
Name:GORUM, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:GORUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6236 OLD HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2426
Mailing Address - Country:US
Mailing Address - Phone:770-928-5536
Mailing Address - Fax:770-928-5541
Practice Address - Street 1:6236 OLD HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2426
Practice Address - Country:US
Practice Address - Phone:770-928-5536
Practice Address - Fax:770-928-5541
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist