Healthcare Provider Details

I. General information

NPI: 1669139648
Provider Name (Legal Business Name): KINGSTON HEALTHCARE CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 GRAND AVE
WAUKEGAN IL
60085-2407
US

IV. Provider business mailing address

1282 CHESTERFIELD LN
GRAYSLAKE IL
60030-3797
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. AVERILL GORDON
Title or Position: OWNER
Credential: PHARM.D.
Phone: 904-477-3853