Provider Demographics
NPI:1275118713
Name:GORDON, JEFFREY DEAN (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DEAN
Last Name:GORDON
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 1:1528 BERNE RD NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1325
Mailing Address - Country:US
Mailing Address - Phone:651-269-8796
Mailing Address - Fax:
Practice Address - Street 1:8400 UNIVERSITY AV NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:651-269-8796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN112313OtherSTATE BOARD IF PHARMACY