Provider Demographics
NPI:1740778430
Name:ILIC, JORDAN CHASE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CHASE
Last Name:ILIC
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 1:3050 WILMA RUDOLPH BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5031
Mailing Address - Country:US
Mailing Address - Phone:931-552-0241
Mailing Address - Fax:
Practice Address - Street 1:3050 WILMA RUDOLPH BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5031
Practice Address - Country:US
Practice Address - Phone:931-552-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17214183500000X
TN38240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist