Provider Demographics
NPI:1760938310
Name:JORDAN, MARK (PHARMACY GRADUATE)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PHARMACY GRADUATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 EAST DIVISION AVENUE
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750
Mailing Address - Country:US
Mailing Address - Phone:231-903-9349
Mailing Address - Fax:
Practice Address - Street 1:5719 US 23
Practice Address - Street 2:
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750
Practice Address - Country:US
Practice Address - Phone:989-739-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist