MEDICARE: DR. AVERILL D GORDON PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS38857	FL
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	051.294042	IL

General Provider Information

NPI Number	:	1164419305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AVERILL D GORDON PHARM.D.

Provider Business Mailing Address
First Line	:	1282 CHESTERFIELD LN
Second Line	:
City	:	GRAYSLAKE
State	:	IL
Zip	:	60030-3797
Country	:	US
Telephone Number	:	904-477-3853
Fax Number	:

Provider Business Practice Location Address
First Line	:	2702 GRAND AVE
Second Line	:
City	:	WAUKEGAN
State	:	IL
Zip	:	60085-2407
Country	:	US
Telephone Number	:	224-441-3008
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	02/14/2024

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