Provider Demographics
NPI:1568171411
Name:KING, JORDAN BRADLEY (PHARMD, MS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:BRADLEY
Last Name:KING
Suffix:
Gender:M
Credentials:PHARMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8490 S TREASURE MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1169
Mailing Address - Country:US
Mailing Address - Phone:509-680-7003
Mailing Address - Fax:
Practice Address - Street 1:295 S CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1287
Practice Address - Country:US
Practice Address - Phone:801-213-1337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8088093-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist