Provider Demographics
NPI:1710110507
Name:GORDON, COURTNEY MARIE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02873-0176
Mailing Address - Country:US
Mailing Address - Phone:401-539-7813
Mailing Address - Fax:
Practice Address - Street 1:14 GORDON WAY
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:RI
Practice Address - Zip Code:02873-0176
Practice Address - Country:US
Practice Address - Phone:401-539-7813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI04707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist