Provider Demographics
NPI:1104426840
Name:GORDON, ASHLEY MARIE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S HIGHWAY 123 BYP
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-9752
Mailing Address - Country:US
Mailing Address - Phone:830-372-5880
Mailing Address - Fax:
Practice Address - Street 1:550 S HIGHWAY 123 BYP
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-9752
Practice Address - Country:US
Practice Address - Phone:830-372-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist