Provider Demographics
NPI:1871870154
Name:GORDILLO, JUAN (RPH)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:GORDILLO
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 1:2719 JON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6346
Mailing Address - Country:US
Mailing Address - Phone:719-330-8799
Mailing Address - Fax:
Practice Address - Street 1:2785 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1360
Practice Address - Country:US
Practice Address - Phone:719-593-8940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14588183500000X
FLPS27887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist