Provider Demographics
NPI:1831647775
Name:JOURDAIN, IVAN F (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:F
Last Name:JOURDAIN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7002
Mailing Address - Country:US
Mailing Address - Phone:212-222-4400
Mailing Address - Fax:212-222-4428
Practice Address - Street 1:691 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7002
Practice Address - Country:US
Practice Address - Phone:212-222-4400
Practice Address - Fax:212-222-4428
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281254Medicaid