Provider Demographics
NPI:1497030167
Name:SKYERS-GORDON-WHITE, IDA H (PHARMD)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:H
Last Name:SKYERS-GORDON-WHITE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17051 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1845
Mailing Address - Country:US
Mailing Address - Phone:760-948-7901
Mailing Address - Fax:
Practice Address - Street 1:17051 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1845
Practice Address - Country:US
Practice Address - Phone:760-948-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist