Provider Demographics
NPI:1265605141
Name:MASWOSWE, JORDAN JONATHAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:JONATHAN
Last Name:MASWOSWE
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:PO BOX 11556
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77391-1556
Mailing Address - Country:US
Mailing Address - Phone:832-761-7817
Mailing Address - Fax:832-761-7821
Practice Address - Street 1:16736 CHAMPION FOREST DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-7024
Practice Address - Country:US
Practice Address - Phone:832-761-7817
Practice Address - Fax:832-761-7821
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX265891835P0018X
MA185771835P0018X
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156759601Medicaid
TX6138570001Medicare NSC