Provider Demographics
NPI:1730448457
Name:GORDONS PHARMACY LLC
Entity type:Organization
Organization Name:GORDONS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-663-2674
Mailing Address - Street 1:3010 US HIGHWAY 80
Mailing Address - Street 2:UNIT B
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:GA
Mailing Address - Zip Code:31302-4558
Mailing Address - Country:US
Mailing Address - Phone:912-988-1780
Mailing Address - Fax:912-988-1784
Practice Address - Street 1:3010 US HIGHWAY 80
Practice Address - Street 2:UNIT B
Practice Address - City:BLOOMINGDALE
Practice Address - State:GA
Practice Address - Zip Code:31302-4558
Practice Address - Country:US
Practice Address - Phone:912-988-1780
Practice Address - Fax:912-988-1784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0098323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125586AMedicaid
1162469OtherNCPDP PROVIDER IDENTIFICATION NUMBER