Provider Demographics
NPI:1831236991
Name:GORDON'S PHARMACY AND GIFTS LLC
Entity type:Organization
Organization Name:GORDON'S PHARMACY AND GIFTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-839-4452
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-0746
Mailing Address - Country:US
Mailing Address - Phone:541-839-4452
Mailing Address - Fax:541-839-4254
Practice Address - Street 1:314 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-0746
Practice Address - Country:US
Practice Address - Phone:541-839-4452
Practice Address - Fax:541-839-4254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000162CS332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR229336Medicaid
3805655OtherNCPDP NUMBER
OR274197Medicaid
R131773Medicare ID - Type UnspecifiedMASS IMMUNIZATION