Healthcare Provider Details

I. General information

NPI: 1003184417
Provider Name (Legal Business Name): ROBERT MARK JORDAN PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 03/23/2023
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HIGHWAY 80 E
CLINTON MS
39056-4716
US

IV. Provider business mailing address

PO BOX 398
FLORA MS
39071-0398
US

V. Phone/Fax

Practice location:
  • Phone: 601-926-1179
  • Fax:
Mailing address:
  • Phone: 601-665-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberE-09972
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE09972
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: