Provider Demographics
NPI:1104148048
Name:GORDON, DONNA LEE (CPHT)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:LEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3001
Mailing Address - Country:US
Mailing Address - Phone:631-543-3331
Mailing Address - Fax:
Practice Address - Street 1:1163 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3001
Practice Address - Country:US
Practice Address - Phone:631-543-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140101489624997183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician