Provider Demographics
NPI:1619441490
Name:WARE, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CATLETTSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41129-9299
Mailing Address - Country:US
Mailing Address - Phone:606-922-9263
Mailing Address - Fax:
Practice Address - Street 1:711 12TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2668
Practice Address - Country:US
Practice Address - Phone:606-325-8231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY020306183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist