Provider Demographics
NPI:1134441454
Name:JORDAN, ERIC RICHARD
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:RICHARD
Last Name:JORDAN
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 1:2 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:NY
Mailing Address - Zip Code:14727-1002
Mailing Address - Country:US
Mailing Address - Phone:585-968-3111
Mailing Address - Fax:585-968-7998
Practice Address - Street 1:2 CENTER ST
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NY
Practice Address - Zip Code:14727-1002
Practice Address - Country:US
Practice Address - Phone:585-968-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01146478Medicaid