Provider Demographics
NPI:1912487166
Name:GIDNEY, JOHN COLLEY JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:COLLEY
Last Name:GIDNEY
Suffix:JR
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 1:7614 SW 49TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-7421
Mailing Address - Country:US
Mailing Address - Phone:772-349-7967
Mailing Address - Fax:
Practice Address - Street 1:5200 SW 34TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-5010
Practice Address - Country:US
Practice Address - Phone:352-375-1496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS58093OtherPHARMACIST