Provider Demographics
NPI:1780296509
Name:ERICKSON, JORDAN LEE (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:ERICKSON
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 1:2109 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4628
Mailing Address - Country:US
Mailing Address - Phone:360-395-8682
Mailing Address - Fax:
Practice Address - Street 1:2109 E BROADWAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4628
Practice Address - Country:US
Practice Address - Phone:360-395-8682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61066697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist