Provider Demographics
NPI:1407239411
Name:JORDAN, TRACEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10188 STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9259
Mailing Address - Country:US
Mailing Address - Phone:810-265-2121
Mailing Address - Fax:
Practice Address - Street 1:105 OAKLEY DR
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-7059
Practice Address - Country:US
Practice Address - Phone:810-265-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25153183500000X
MI5302047388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist