Provider Demographics
NPI:1922176288
Name:JORDAN, ROY B (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:B
Last Name:JORDAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 HIGHWAY 16 S
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76450-4202
Mailing Address - Country:US
Mailing Address - Phone:940-549-1011
Mailing Address - Fax:940-549-0716
Practice Address - Street 1:1332 HIGHWAY 16 S
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-4202
Practice Address - Country:US
Practice Address - Phone:940-549-1011
Practice Address - Fax:940-549-0716
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143816Medicaid
TX0952110001Medicare NSC