Provider Demographics
NPI:1346670726
Name:CHARLES R GORDON MD PA
Entity Type:Organization
Organization Name:CHARLES R GORDON MD PA
Other - Org Name:ROSELAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GM
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-720-9910
Mailing Address - Street 1:PO BOX 8967
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-8967
Mailing Address - Country:US
Mailing Address - Phone:903-531-0590
Mailing Address - Fax:903-531-0591
Practice Address - Street 1:2737 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5413
Practice Address - Country:US
Practice Address - Phone:903-531-0590
Practice Address - Fax:903-531-0591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX288823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143181OtherPK