Provider Demographics
NPI:1386005726
Name:GORDON, SELENA
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 S LEMAY AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3288
Mailing Address - Country:US
Mailing Address - Phone:970-490-1128
Mailing Address - Fax:970-490-1136
Practice Address - Street 1:731 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3288
Practice Address - Country:US
Practice Address - Phone:970-490-1128
Practice Address - Fax:970-490-1136
Is Sole Proprietor?:No
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist