Provider Demographics
NPI:1588259766
Name:CHRISTOFFERSON, JON ROSS
Entity type:Individual
Prefix:
First Name:JON
Middle Name:ROSS
Last Name:CHRISTOFFERSON
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 1:2630 E MOHAWK LN STE 128
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4637
Mailing Address - Country:US
Mailing Address - Phone:602-252-1299
Mailing Address - Fax:
Practice Address - Street 1:2630 E MOHAWK LN STE 128
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4637
Practice Address - Country:US
Practice Address - Phone:602-252-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSO18241183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist