Healthcare Provider Details

I. General information

NPI: 1104219740
Provider Name (Legal Business Name): RYAN GORDON PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 W LEHIGH AVE
PHILADELPHIA PA
19133-3425
US

IV. Provider business mailing address

2600 WELSH RD APT 20
PHILADELPHIA PA
19152-1442
US

V. Phone/Fax

Practice location:
  • Phone: 215-425-3784
  • Fax:
Mailing address:
  • Phone: 347-512-4913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP449061
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: