Healthcare Provider Details

I. General information

NPI: 1104742782
Provider Name (Legal Business Name): IRINA GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CORPORATE DR
LAKE ZURICH IL
60047-8930
US

IV. Provider business mailing address

3 CORPORATE DR
LAKE ZURICH IL
60047-8930
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051289494
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: