=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720220304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDAN J MASWOSWE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2009
-----------------------------------------------------
Last Update Date | 08/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6402 LOUETTA RD SUITE 145
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-7580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-953-2782
-----------------------------------------------------
Fax | 832-953-2784
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11556
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77391-1556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-446-6826
-----------------------------------------------------
Fax | 832-553-7400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JORDAN MASWOSWE
-----------------------------------------------------
Credential | BSC., PHARMD
-----------------------------------------------------
Telephone | 713-446-6826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 25425
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------