Provider Demographics
NPI:1477835742
Name:HACK GORDON, JAMIE VIRGINIA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:VIRGINIA
Last Name:HACK GORDON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9855 HUNTING TR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-3515
Mailing Address - Country:US
Mailing Address - Phone:561-968-3330
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214400183500000X
COPHA.0023069183500000X
WVRP0012244183500000X
FLPS45154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPHA.0023069OtherCOLORADO BOARD OF PHARMACY
WVRP0012244OtherWEST VIRGINIA BOARD OF PHARMACY
VA0202214400OtherVIRGINIA BOARD OF PHARMACY
FLPS45154OtherFLORIDA BOARD OF PHARMACY