Healthcare Provider Details

I. General information

NPI: 1255047825
Provider Name (Legal Business Name): KINGSTON HEALTHCARE CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date: 02/02/2024
Reactivation Date: 08/19/2024

III. Provider practice location address

2702 GRAND AVE
WAUKEGAN IL
60085-2407
US

IV. Provider business mailing address

1282 CHESTERFIELD LN
GRAYSLAKE IL
60030
US

V. Phone/Fax

Practice location:
  • Phone: 244-441-3008
  • Fax: 224-441-3016
Mailing address:
  • Phone: 904-477-3853
  • Fax: 224-252-3914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. AVERILL GORDON
Title or Position: PHARMACIST/OWNER
Credential: PHARMD
Phone: 904-477-3853