Healthcare Provider Details

I. General information

NPI: 1891496998
Provider Name (Legal Business Name): TRACY L JORDAN R.PH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 BIG A RD S
TOCCOA GA
30577-3166
US

IV. Provider business mailing address

PO BOX 385
HOSCHTON GA
30548-0385
US

V. Phone/Fax

Practice location:
  • Phone: 706-866-8575
  • Fax: 706-866-8711
Mailing address:
  • Phone: 706-540-8096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16509
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: