Healthcare Provider Details

I. General information

NPI: 1114329968
Provider Name (Legal Business Name): GORDON JAMES CARROLL PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 MAIN ST
CARBONDALE KS
66414-9714
US

IV. Provider business mailing address

211 MAIN ST
CARBONDALE KS
66414-9714
US

V. Phone/Fax

Practice location:
  • Phone: 785-836-7202
  • Fax: 785-836-7208
Mailing address:
  • Phone: 785-836-7202
  • Fax: 785-836-7208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-15969
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: