Provider Demographics
NPI:1407134935
Name:DAVIS, JORDAN CLARK (PHARM D)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CLARK
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-0208
Mailing Address - Country:US
Mailing Address - Phone:928-475-2371
Mailing Address - Fax:928-475-7272
Practice Address - Street 1:1223 CIBECUE CIR
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550-0208
Practice Address - Country:US
Practice Address - Phone:928-475-2371
Practice Address - Fax:928-475-7272
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist