Provider Demographics
NPI:1538786769
Name:DIMOCK, JORDAN A (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:A
Last Name:DIMOCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 AMBERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7943
Mailing Address - Country:US
Mailing Address - Phone:803-528-3054
Mailing Address - Fax:
Practice Address - Street 1:2401 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4717
Practice Address - Country:US
Practice Address - Phone:803-796-8126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist