Provider Demographics
NPI:1669220703
Name:JORDAAN, DOUGLAS HARRY
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:HARRY
Last Name:JORDAAN
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 1:26612 ALTANERO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-1504
Mailing Address - Country:US
Mailing Address - Phone:949-806-0818
Mailing Address - Fax:
Practice Address - Street 1:26612 ALTANERO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-1504
Practice Address - Country:US
Practice Address - Phone:949-806-0818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist