Provider Demographics
NPI:1760025340
Name:GORDON, MATTHEW (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
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 1:1601 W KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1844
Mailing Address - Country:US
Mailing Address - Phone:813-254-6309
Mailing Address - Fax:
Practice Address - Street 1:1601 W KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-1844
Practice Address - Country:US
Practice Address - Phone:813-254-6309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist