Provider Demographics
NPI:1881297398
Name:GORDON, KORI RAYMER
Entity type:Individual
Prefix:
First Name:KORI
Middle Name:RAYMER
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 KAVANAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-4747
Mailing Address - Country:US
Mailing Address - Phone:501-664-3844
Mailing Address - Fax:
Practice Address - Street 1:5008 KAVANAUGH BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-4747
Practice Address - Country:US
Practice Address - Phone:501-664-3844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist