Provider Demographics
NPI:1265726319
Name:JORDAN, TRACY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 GRANDSTAND PL STE 300
Mailing Address - Street 2:GENOA HEALTHCARE 106
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4987
Mailing Address - Country:US
Mailing Address - Phone:224-276-7236
Mailing Address - Fax:847-888-0640
Practice Address - Street 1:1845 GRANDSTAND PL STE 300
Practice Address - Street 2:GENOA HEALTHCARE 106
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4987
Practice Address - Country:US
Practice Address - Phone:224-276-7236
Practice Address - Fax:847-888-0640
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist