Healthcare Provider Details

I. General information

NPI: 1689619348
Provider Name (Legal Business Name): JORDAN DRUG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 05/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

842 HIGHWAY 15 NORTH
JACKSON KY
41339-1017
US

IV. Provider business mailing address

PO BOX 346
BEATTYVILLE KY
41311-0346
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-7060
  • Fax: 606-666-9454
Mailing address:
  • Phone: 606-464-3901
  • Fax: 606-464-8888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP06509
License Number StateKY

VIII. Authorized Official

Name: ROSEMAYR C SMITH
Title or Position: SEC/TREAS
Credential: R. PH.
Phone: 606-464-3901