Provider Demographics
NPI:1346726692
Name:GORDY, DENICE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DENICE
Middle Name:
Last Name:GORDY
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:DEWANNA
Other - Middle Name:DENICE
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:1647 HIGHWAY 124 E
Mailing Address - Street 2:
Mailing Address - City:KELLY
Mailing Address - State:LA
Mailing Address - Zip Code:71441-2028
Mailing Address - Country:US
Mailing Address - Phone:318-495-3558
Mailing Address - Fax:
Practice Address - Street 1:3670 W OAK ST
Practice Address - Street 2:
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342-4474
Practice Address - Country:US
Practice Address - Phone:318-992-1357
Practice Address - Fax:318-992-1359
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1346267614OtherNPI