Provider Demographics
NPI:1255668166
Name:JORDAN, PHAEDRA M (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:PHAEDRA
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 W MCDERMOTT DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6304
Mailing Address - Country:US
Mailing Address - Phone:972-396-0753
Mailing Address - Fax:972-359-0584
Practice Address - Street 1:1226 W MCDERMOTT DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6304
Practice Address - Country:US
Practice Address - Phone:972-396-0753
Practice Address - Fax:972-359-0584
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist