Provider Demographics
NPI:1114645082
Name:RUPP, JORDAN DAVID (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:DAVID
Last Name:RUPP
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 E PONY EXPRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5512
Mailing Address - Country:US
Mailing Address - Phone:801-789-4997
Mailing Address - Fax:
Practice Address - Street 1:4045 E PONY EXPRESS PKWY
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5512
Practice Address - Country:US
Practice Address - Phone:801-789-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7720480-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist