Provider Demographics
NPI:1568903532
Name:FIRST CHOICE PHARMACY OF JORDAN PC
Entity Type:Organization
Organization Name:FIRST CHOICE PHARMACY OF JORDAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHARM
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:REINHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-855-4381
Mailing Address - Street 1:165 WEST COMMERCE DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BELLE PLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:56011
Mailing Address - Country:US
Mailing Address - Phone:952-855-4381
Mailing Address - Fax:952-855-4015
Practice Address - Street 1:165 WEST COMMERCE DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:BELLE PLAINE
Practice Address - State:MN
Practice Address - Zip Code:56011
Practice Address - Country:US
Practice Address - Phone:952-855-4381
Practice Address - Fax:952-855-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2653083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1568903532Medicaid
2167656OtherPK