Provider Demographics
NPI:1477924272
Name:DAVIS, JORDAN LEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:DAVIS
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 1:7670 MARTINSBURG PIKE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-3698
Mailing Address - Country:US
Mailing Address - Phone:304-876-9966
Mailing Address - Fax:304-876-6655
Practice Address - Street 1:7670 MARTINSBURG PIKE
Practice Address - Street 2:SUITE 2
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-3698
Practice Address - Country:US
Practice Address - Phone:304-876-9966
Practice Address - Fax:304-876-6655
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211171183500000X
WVRP0009421183500000X
KY016157183500000X
NHR2365183500000X
GARPH023703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist