Provider Demographics
NPI:1093312852
Name:SKINNER, GORDON SCOTT (RPH)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:SCOTT
Last Name:SKINNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LANE 100 LAKE ARROWHEAD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:IN
Mailing Address - Zip Code:46747-9783
Mailing Address - Country:US
Mailing Address - Phone:260-665-5205
Mailing Address - Fax:
Practice Address - Street 1:2016 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-9102
Practice Address - Country:US
Practice Address - Phone:260-665-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018676A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist