Provider Demographics
NPI:1528464336
Name:WEST GORDON PHARMACY INC
Entity type:Organization
Organization Name:WEST GORDON PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-512-2102
Mailing Address - Street 1:3225 W GORDON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5728
Mailing Address - Country:US
Mailing Address - Phone:801-544-7979
Mailing Address - Fax:801-682-8011
Practice Address - Street 1:3225 W GORDON AVE STE 2
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5728
Practice Address - Country:US
Practice Address - Phone:801-544-7979
Practice Address - Fax:801-682-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
UT9221852-17033336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149549OtherPK
UT1528464336Medicaid