Healthcare Provider Details

I. General information

NPI: 1477124147
Provider Name (Legal Business Name): JONATHAN C GORDON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 07/05/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18525 HIGHWAY 22
MAUREPAS LA
70449-3015
US

IV. Provider business mailing address

22840 ALEX WILLIE RD
LIVINGSTON LA
70754-5250
US

V. Phone/Fax

Practice location:
  • Phone: 225-267-4340
  • Fax:
Mailing address:
  • Phone: 225-290-1536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number023907
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: