MEDICARE: GORDONS PHARMACY LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHRE009832	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1162469	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1730448457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GORDONS PHARMACY LLC

Provider Business Mailing Address
First Line	:	3010 US HIGHWAY 80
Second Line	:	UNIT B
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-4558
Country	:	US
Telephone Number	:	912-988-1780
Fax Number	:	912-988-1784

Provider Business Practice Location Address
First Line	:	3010 US HIGHWAY 80
Second Line	:	UNIT B
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-4558
Country	:	US
Telephone Number	:	912-988-1780
Fax Number	:	912-988-1784

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVEN GORDON
Credential	:
Telephone Number	:	912-663-2674

Provider Enumeration Date	:	05/15/2012
Last Update Date	:	08/21/2012

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