Provider Demographics
NPI:1780024158
Name:GORDON, WILHELMINA
Entity Type:Individual
Prefix:
First Name:WILHELMINA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WILHELMINA
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1314 E CATHEDRAL ROCK DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-6203
Mailing Address - Country:US
Mailing Address - Phone:480-213-1235
Mailing Address - Fax:
Practice Address - Street 1:4747 E ELLIOT RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-1627
Practice Address - Country:US
Practice Address - Phone:480-281-1019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist