Provider Demographics
NPI:1578660411
Name:JORDAN PHARMACY INC
Entity Type:Organization
Organization Name:JORDAN PHARMACY INC
Other - Org Name:JORDAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:254-386-3111
Mailing Address - Street 1:107 N RICE ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:TX
Mailing Address - Zip Code:76531-1857
Mailing Address - Country:US
Mailing Address - Phone:254-386-3111
Mailing Address - Fax:254-386-8844
Practice Address - Street 1:107 N RICE ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:TX
Practice Address - Zip Code:76531-1857
Practice Address - Country:US
Practice Address - Phone:254-386-3111
Practice Address - Fax:254-386-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336C0003X
TX219583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2096994OtherPK
TX0145199Medicaid
TX0145199Medicaid
4521541OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4544550001Medicare NSC
TX159646001Medicaid