Provider Demographics
NPI:1720566151
Name:GORDON, JOHN (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GORDON
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 1:18740 SE RIVER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-8106
Mailing Address - Country:US
Mailing Address - Phone:561-748-0365
Mailing Address - Fax:
Practice Address - Street 1:18740 SE RIVER RIDGE RD
Practice Address - Street 2:
Practice Address - City:TEQUESTA
Practice Address - State:FL
Practice Address - Zip Code:33469-8106
Practice Address - Country:US
Practice Address - Phone:561-748-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist