Provider Demographics
NPI:1982817102
Name:JORDAN PHARMACY
Entity Type:Organization
Organization Name:JORDAN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:B
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:940-549-1011
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX148123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0102188-01OtherTX MEDICAID & HEALTHCARE
TX143816Medicaid
TX0102188-01OtherTX MEDICAID & HEALTHCARE