MEDICARE: NEISHA GORDON PHARMACIST

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	PS57455	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS57455	OTHER	FL	FLORIDA DEPARTMENT OF HEALTH, BOARD OF PHARMACY

General Provider Information

NPI Number	:	1497242010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEISHA GORDON PHARMACIST

Provider Business Mailing Address
First Line	:	701 SW LAKEHURST DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-2461
Country	:	US
Telephone Number	:	443-253-6470
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 SE FLORESTA DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-4069
Country	:	US
Telephone Number	:	772-340-4142
Fax Number	:

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

Provider Enumeration Date	:	04/19/2018
Last Update Date	:	04/19/2018

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