Provider Demographics
NPI:1417226226
Name:GORDON, KYIA
Entity Type:Individual
Prefix:
First Name:KYIA
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 1:6975 YORK AVE S
Mailing Address - Street 2:WALGREENS PHARMACY
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6975 YORK AVE S
Practice Address - Street 2:WALGREENS PHARMACY
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2517
Practice Address - Country:US
Practice Address - Phone:952-920-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist