Healthcare Provider Details

I. General information

NPI: 1093165235
Provider Name (Legal Business Name): ELIZABETH DIAL JORDAN PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 06/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 N CRAFT HWY
CHICKASAW AL
36611-1312
US

IV. Provider business mailing address

414 N CRAFT HWY
CHICKASAW AL
36611-1312
US

V. Phone/Fax

Practice location:
  • Phone: 251-452-0531
  • Fax: 251-456-1529
Mailing address:
  • Phone: 251-452-0531
  • Fax: 251-456-1529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14372
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: