Provider Demographics
NPI:1699175562
Name:GOURDIKIAN, KEROP B
Entity type:Individual
Prefix:DR
First Name:KEROP
Middle Name:B
Last Name:GOURDIKIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:K
Other - Middle Name:B
Other - Last Name:GOURDIKIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:R PH
Mailing Address - Street 1:2605 HAMILTON MILL RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4106
Mailing Address - Country:US
Mailing Address - Phone:678-546-5352
Mailing Address - Fax:
Practice Address - Street 1:3505 CENTERVILLE HWY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-6405
Practice Address - Country:US
Practice Address - Phone:770-736-2157
Practice Address - Fax:770-736-9340
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist