Provider Demographics
NPI:1154796456
Name:GORDON, KENNETH (PHARM D)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 NW 81ST TER
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5050
Mailing Address - Country:US
Mailing Address - Phone:813-505-4604
Mailing Address - Fax:
Practice Address - Street 1:5261 NW 81ST TER
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-5050
Practice Address - Country:US
Practice Address - Phone:813-505-4604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist