Provider Demographics
NPI:1578904017
Name:DANIEL, JORDAN THOMAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:THOMAS
Last Name:DANIEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DEVEREUX ST
Mailing Address - Street 2:#217
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-5556
Mailing Address - Country:US
Mailing Address - Phone:317-287-4152
Mailing Address - Fax:
Practice Address - Street 1:1 CVS DR
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-6146
Practice Address - Country:US
Practice Address - Phone:401-770-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52073183500000X
RIRPH05362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist