Provider Demographics
NPI:1689619348
Name:JORDAN DRUG, INC.
Entity Type:Organization
Organization Name:JORDAN DRUG, INC.
Other - Org Name:JACKSON APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC/TREAS
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMAYR
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:606-464-3901
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0346
Mailing Address - Country:US
Mailing Address - Phone:606-464-3901
Mailing Address - Fax:606-464-8888
Practice Address - Street 1:842 HIGHWAY 15 NORTH
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-1017
Practice Address - Country:US
Practice Address - Phone:606-666-7060
Practice Address - Fax:606-666-9454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X
KYP065093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYFLU0298OtherMEDICARE FLU
KY9000134800OtherDME MEDICAID
KY5400000500Medicaid
KYFLU0298OtherMEDICARE FLU