Basic Information
| Provider Information | |||||||||
| NPI: | 1407134935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PHARM D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 208 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855500208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284752371 | ||||||||
| FaxNumber: | 9284757272 | ||||||||
| Practice Location | |||||||||
| Address1: | 1223 CIBECUE CIR | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855500208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284752371 | ||||||||
| FaxNumber: | 9284757272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2011 | ||||||||
| LastUpdateDate: | 08/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S018104 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.