Provider Demographics
NPI:1134500473
Name:GORDON, KIMBERLY ALLISON (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ALLISON
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:ALLISON
Other - Last Name:COLBETH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1 QUALITY DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9494
Mailing Address - Country:US
Mailing Address - Phone:802-779-1494
Mailing Address - Fax:
Practice Address - Street 1:1550 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6901
Practice Address - Country:US
Practice Address - Phone:802-779-1494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist