Provider Demographics
NPI:1295762987
Name:JORDAN DRUG, INC.
Entity type:Organization
Organization Name:JORDAN DRUG, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SEC/TREAS
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:606-464-3901
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0346
Mailing Address - Country:US
Mailing Address - Phone:606-464-3901
Mailing Address - Fax:606-464-8888
Practice Address - Street 1:4644 HIGHWAY 15 WEST
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:KY
Practice Address - Zip Code:40312
Practice Address - Country:US
Practice Address - Phone:606-663-3481
Practice Address - Fax:606-663-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X
KYP064583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5403457400Medicaid
KY9000102500OtherDME MEDICAID
KYFLU0298OtherMEDICARE FLU
KY5403457400Medicaid