Provider Demographics
NPI:1457854622
Name:CARRILLO, JORDAN
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:CARRILLO
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 1:8524 MASON ANDREW WAY APT 2116
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-0267
Mailing Address - Country:US
Mailing Address - Phone:980-254-2323
Mailing Address - Fax:980-254-2323
Practice Address - Street 1:640 JAKE ALEXANDER BLVD W
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1367
Practice Address - Country:US
Practice Address - Phone:704-636-8852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC275200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist