Provider Demographics
NPI:1083216881
Name:GORDON, MARIA CHRISTINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:CHRISTINA
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:C
Other - Last Name:TANGONAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:18 S DIANE HOLLOW WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1668
Mailing Address - Country:US
Mailing Address - Phone:708-890-0106
Mailing Address - Fax:
Practice Address - Street 1:13502 S HAMILTON VIEW RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-6064
Practice Address - Country:US
Practice Address - Phone:801-446-2991
Practice Address - Fax:801-446-2994
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10240933-1701183500000X
IL051.1297740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist