Provider Demographics
NPI:1861712754
Name:GRAHAM, GORDON HOWELL (RPH)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:HOWELL
Last Name:GRAHAM
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 1:1112 NIPIGON CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6736
Mailing Address - Country:US
Mailing Address - Phone:757-721-6416
Mailing Address - Fax:
Practice Address - Street 1:5300 PRINCESS ANNE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5904
Practice Address - Country:US
Practice Address - Phone:757-497-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist