Provider Demographics
NPI:1821554502
Name:GORDON, NICHOLAS RYAN (PHARMD,RPH)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RYAN
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHARMD,RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 STANTON ST APT 704
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-5649
Mailing Address - Country:US
Mailing Address - Phone:802-379-6912
Mailing Address - Fax:
Practice Address - Street 1:83 VANDENBURGH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-6086
Practice Address - Country:US
Practice Address - Phone:518-272-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist