Provider Demographics
NPI:1205350170
Name:EZEANYIM, JORDAN (PHARMD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:EZEANYIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2822 ARCE LN SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-3290
Mailing Address - Country:US
Mailing Address - Phone:505-310-0776
Mailing Address - Fax:
Practice Address - Street 1:1096 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1654
Practice Address - Country:US
Practice Address - Phone:505-982-9811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist