Individual
JORDAN MATTHEW LIST
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHARM.D.
Contact information
Practice address
VA MEDICAL CENTER, 500 W FORT STREET (119), BOISE, ID 83702-4598
(208) 422-1000
Mailing address
5645 S DAFFODIL PL, BOISE, ID 83716-6952
(785) 550-3724
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
1-14481
KS
Other
Enumeration date
07/23/2009
Last updated
07/23/2009
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