Healthcare Provider Details

I. General information

NPI: 1770187635
Provider Name (Legal Business Name): JONATHAN MARTIN MIDGORDEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2020
Last Update Date: 11/22/2020
Certification Date: 11/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 E US HIGHWAY 24
INDEPENDENCE MO
64054-1567
US

IV. Provider business mailing address

1012 SW 14TH ST
LEES SUMMIT MO
64081-3234
US

V. Phone/Fax

Practice location:
  • Phone: 816-833-2493
  • Fax: 816-461-5817
Mailing address:
  • Phone: 816-225-8421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2014027817
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: