=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992231906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON KOST RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 CEDAR CREEK CT APT 159
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-5250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-447-8475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 CEDAR CREEK CT APT 159
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-5250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-447-8475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26560
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------