Provider Demographics
NPI:1710587605
Name:REED, JORDAN TYLER
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:TYLER
Last Name:REED
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 1:2875 W MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7625
Mailing Address - Country:US
Mailing Address - Phone:479-521-4350
Mailing Address - Fax:479-521-4508
Practice Address - Street 1:2875 W MLK BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7625
Practice Address - Country:US
Practice Address - Phone:479-521-4350
Practice Address - Fax:479-521-4508
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist