Provider Demographics
NPI:1225808918
Name:HAYNES, JORDAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:HAYNES
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 MACCORKLE AVE SW STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1444
Mailing Address - Country:US
Mailing Address - Phone:304-766-8484
Mailing Address - Fax:304-766-8344
Practice Address - Street 1:4501 MACCORKLE AVE SW STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1444
Practice Address - Country:US
Practice Address - Phone:304-766-8484
Practice Address - Fax:304-766-8344
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0013997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist