Provider Demographics
NPI:1477124147
Name:GORDON, JONATHAN C (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22840 ALEX WILLIE RD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:LA
Mailing Address - Zip Code:70754-5250
Mailing Address - Country:US
Mailing Address - Phone:225-290-1536
Mailing Address - Fax:
Practice Address - Street 1:18525 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:MAUREPAS
Practice Address - State:LA
Practice Address - Zip Code:70449-3015
Practice Address - Country:US
Practice Address - Phone:225-267-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist