Provider Demographics
NPI:1841536273
Name:GARIBOLDI, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GARIBOLDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WADE HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-2781
Mailing Address - Country:US
Mailing Address - Phone:864-609-7310
Mailing Address - Fax:
Practice Address - Street 1:2801 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-2781
Practice Address - Country:US
Practice Address - Phone:864-609-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist