Provider Demographics
NPI:1477731255
Name:JORDAN, GARY M (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:JORDAN
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 1:294 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-4428
Mailing Address - Country:US
Mailing Address - Phone:631-736-5168
Mailing Address - Fax:631-736-5733
Practice Address - Street 1:294 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4428
Practice Address - Country:US
Practice Address - Phone:631-736-5168
Practice Address - Fax:631-736-5733
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030503-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist