Provider Demographics
NPI:1578444808
Name:GORDON, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2407
Mailing Address - Country:US
Mailing Address - Phone:801-756-2411
Mailing Address - Fax:801-756-6824
Practice Address - Street 1:135 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2407
Practice Address - Country:US
Practice Address - Phone:801-756-2411
Practice Address - Fax:801-756-6824
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT132311-17013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy