Provider Demographics
NPI:1639419831
Name:GRDGON, MATTHEW JAMES (CPHT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAMES
Last Name:GRDGON
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 2ND AVE SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3120
Mailing Address - Country:US
Mailing Address - Phone:727-581-9382
Mailing Address - Fax:727-585-5818
Practice Address - Street 1:1301 2ND AVE SW
Practice Address - Street 2:SUITE 200
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3120
Practice Address - Country:US
Practice Address - Phone:727-581-9382
Practice Address - Fax:727-585-5818
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049-181910183700000X
FLRPT4684183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician