Provider Demographics
NPI:1922411982
Name:GORDON, STACEY (RPH)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18700 N VILLAGE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2454
Mailing Address - Country:US
Mailing Address - Phone:301-791-0606
Mailing Address - Fax:
Practice Address - Street 1:18700 N VILLAGE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2454
Practice Address - Country:US
Practice Address - Phone:301-791-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-08
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist