Provider Demographics
NPI:1093231037
Name:JORDAN, ROCHELLE REED
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:REED
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 MURPHY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-7832
Mailing Address - Country:US
Mailing Address - Phone:662-582-1206
Mailing Address - Fax:
Practice Address - Street 1:603 MIDDLETON RD
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-2021
Practice Address - Country:US
Practice Address - Phone:662-283-1393
Practice Address - Fax:662-283-5103
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE7354183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist