Provider Demographics
NPI:1649093378
Name:GORDON, GARRY L II
Entity type:Individual
Prefix:MR
First Name:GARRY
Middle Name:L
Last Name:GORDON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6671
Mailing Address - Country:US
Mailing Address - Phone:865-466-7372
Mailing Address - Fax:
Practice Address - Street 1:1797 ROANE STATE HWY
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-8306
Practice Address - Country:US
Practice Address - Phone:865-717-2835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000084995183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician