Provider Demographics
NPI:1538145180
Name:GORDON, JOHN G (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:G
Last Name:GORDON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 RAINIER AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2434
Mailing Address - Country:US
Mailing Address - Phone:425-252-7493
Mailing Address - Fax:
Practice Address - Street 1:115 N GRANITE AVE
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252-2348
Practice Address - Country:US
Practice Address - Phone:360-691-7778
Practice Address - Fax:360-691-4458
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH15083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist