Provider Demographics
NPI:1700804903
Name:JORDAN, PENNY ELLEN (CPHT)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:ELLEN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1220 BLACKSTONE CT NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-9071
Mailing Address - Country:US
Mailing Address - Phone:704-723-9423
Mailing Address - Fax:704-723-9486
Practice Address - Street 1:5006 HIGHWAY 49 S
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-8465
Practice Address - Country:US
Practice Address - Phone:704-454-7948
Practice Address - Fax:704-455-8457
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC01985183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician