Provider Demographics
NPI:1194300749
Name:CORDOBA, JAIME
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:CORDOBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 W WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-2734
Mailing Address - Country:US
Mailing Address - Phone:775-867-3700
Mailing Address - Fax:775-867-3747
Practice Address - Street 1:461 W WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-2734
Practice Address - Country:US
Practice Address - Phone:775-867-3700
Practice Address - Fax:775-867-3747
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist