Healthcare Provider Details

I. General information

NPI: 1013269778
Provider Name (Legal Business Name): JORDAN ROYCE NEWMAN R.PH., PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 28TH ST SE
GRAND RAPIDS MI
49508-1412
US

IV. Provider business mailing address

1540 28TH ST SE
GRAND RAPIDS MI
49508-1412
US

V. Phone/Fax

Practice location:
  • Phone: 616-452-3142
  • Fax: 616-248-2665
Mailing address:
  • Phone: 616-452-3142
  • Fax: 616-248-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302039457
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number016647
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: