Provider Demographics
NPI:1386766186
Name:GORDON, RANDAL DAVID (RPH)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:DAVID
Last Name:GORDON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 CATHEDRAL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3737
Mailing Address - Country:US
Mailing Address - Phone:248-932-0921
Mailing Address - Fax:
Practice Address - Street 1:26020 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1415
Practice Address - Country:US
Practice Address - Phone:248-545-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist