Provider Demographics
NPI:1689235749
Name:MAZZOTTI, GORDON JOHN (R PH)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:JOHN
Last Name:MAZZOTTI
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W MAIN CROSS ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2247
Mailing Address - Country:US
Mailing Address - Phone:217-254-4162
Mailing Address - Fax:
Practice Address - Street 1:315 N WEBSTER ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1555
Practice Address - Country:US
Practice Address - Phone:217-824-8154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-027614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist