Provider Demographics
NPI:1407631617
Name:ANDERSON, JORDAN (RPH)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ANDERSON
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 1:1535 OAK FOREST SPUR DR APT B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-1957
Mailing Address - Country:US
Mailing Address - Phone:630-835-7002
Mailing Address - Fax:
Practice Address - Street 1:3029 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8696
Practice Address - Country:US
Practice Address - Phone:636-240-7749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023032596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist