Provider Demographics
NPI:1629670377
Name:ROCKHOLD, JORDAN MICHAEL
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICHAEL
Last Name:ROCKHOLD
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 1:96 PATRICK HENRY WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-4391
Mailing Address - Country:US
Mailing Address - Phone:304-728-2190
Mailing Address - Fax:
Practice Address - Street 1:96 PATRICK HENRY WAY
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-4391
Practice Address - Country:US
Practice Address - Phone:304-728-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0008703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist