Provider Demographics
NPI:1619291705
Name:MILFORD, GORDON WILLIAM WAYNE (RPH)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:WILLIAM WAYNE
Last Name:MILFORD
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 1:3249 E DOWLING MILL CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5796
Mailing Address - Country:US
Mailing Address - Phone:208-949-3139
Mailing Address - Fax:
Practice Address - Street 1:3249 E DOWLING MILL CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5796
Practice Address - Country:US
Practice Address - Phone:208-949-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist