Provider Demographics
NPI:1609217447
Name:GORDON, NICOLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2352 SHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-8923
Mailing Address - Country:US
Mailing Address - Phone:209-847-4149
Mailing Address - Fax:
Practice Address - Street 1:2352 SHIRE WAY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-8923
Practice Address - Country:US
Practice Address - Phone:209-847-4149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist