Provider Demographics
NPI:1497242010
Name:GORDON, NEISHA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:NEISHA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SW LAKEHURST DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2461
Mailing Address - Country:US
Mailing Address - Phone:443-253-6470
Mailing Address - Fax:
Practice Address - Street 1:1550 SE FLORESTA DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-4069
Practice Address - Country:US
Practice Address - Phone:772-340-4142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS57455OtherFLORIDA DEPARTMENT OF HEALTH, BOARD OF PHARMACY