Provider Demographics
NPI:1043822653
Name:GAGNON, JONATHAN BARTLETT (PHARM D)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BARTLETT
Last Name:GAGNON
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 1:1350 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8945
Mailing Address - Country:US
Mailing Address - Phone:321-254-5507
Mailing Address - Fax:321-254-5032
Practice Address - Street 1:1350 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8945
Practice Address - Country:US
Practice Address - Phone:321-254-5507
Practice Address - Fax:321-254-5032
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist