Provider Demographics
NPI:1851819890
Name:JORDAN, SOPHIA RAQUEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:RAQUEL
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 AVIARY CT NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5744
Mailing Address - Country:US
Mailing Address - Phone:678-358-3255
Mailing Address - Fax:
Practice Address - Street 1:5230 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-4263
Practice Address - Country:US
Practice Address - Phone:770-792-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist