Provider Demographics
NPI:1376236588
Name:SISK, JORDAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SISK
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 1:781 COUNTY ROAD 312
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:AL
Mailing Address - Zip Code:35963-4103
Mailing Address - Country:US
Mailing Address - Phone:256-706-0060
Mailing Address - Fax:
Practice Address - Street 1:103 GREENHILL BLVD NW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-3701
Practice Address - Country:US
Practice Address - Phone:256-845-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist