Provider Demographics
NPI:1003428194
Name:RICHARDSON, JORDAN KYLE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KYLE
Last Name:RICHARDSON
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 1:1650 E ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4274
Mailing Address - Country:US
Mailing Address - Phone:423-638-4889
Mailing Address - Fax:
Practice Address - Street 1:1650 E ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4274
Practice Address - Country:US
Practice Address - Phone:423-638-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41424183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist