Healthcare Provider Details

I. General information

NPI: 1538145180
Provider Name (Legal Business Name): JOHN G GORDON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N GRANITE AVE
GRANITE FALLS WA
98252-2348
US

IV. Provider business mailing address

2101 RAINIER AVE
EVERETT WA
98201-2434
US

V. Phone/Fax

Practice location:
  • Phone: 360-691-7778
  • Fax: 360-691-4458
Mailing address:
  • Phone: 425-252-7493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH15083
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: