Provider Demographics
NPI:1497277131
Name:ROBBELOTH, JORDAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ROBBELOTH
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 1:1910 MARVY LN NE
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:IN
Mailing Address - Zip Code:47164-8334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1106 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2370
Practice Address - Country:US
Practice Address - Phone:812-246-5405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027149A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist