Provider Demographics
NPI:1275693996
Name:ALDERSHOF, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ALDERSHOF
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 1:113 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-1422
Mailing Address - Country:US
Mailing Address - Phone:319-363-0074
Mailing Address - Fax:
Practice Address - Street 1:113 1ST ST E
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1422
Practice Address - Country:US
Practice Address - Phone:319-895-6248
Practice Address - Fax:319-895-6991
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist