Provider Demographics
NPI:1134621261
Name:CANANKAMP, JORDAN (PHARMD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CANANKAMP
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21961 NE CHINOOK WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-8615
Mailing Address - Country:US
Mailing Address - Phone:814-644-1581
Mailing Address - Fax:
Practice Address - Street 1:1097 FLEDDERJOHN RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314
Practice Address - Country:US
Practice Address - Phone:304-345-3627
Practice Address - Fax:304-346-4440
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0016706183500000X, 1835P2201X
OH03237491183500000X
WVRP0010235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist