Provider Demographics
NPI:1689974198
Name:GORDER, RANDOLPH M (RPH)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:M
Last Name:GORDER
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 1:3970 STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3002
Mailing Address - Country:US
Mailing Address - Phone:928-681-4903
Mailing Address - Fax:
Practice Address - Street 1:3970 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3002
Practice Address - Country:US
Practice Address - Phone:928-681-4903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-31
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8167OtherAZ PHARMACY LICENSE
SD4042OtherSD PHARMACY LICENSE #