MEDICARE: DR. ELIZABETH DIAL JORDAN PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	14372	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS39299	OTHER	FL	REGISTERED PHARMACIST- INACTIVE STATUS
2	14372	OTHER	AL	REGISTERED PHARMACIST

General Provider Information

NPI Number	:	1093165235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH DIAL JORDAN PHARM.D.

Provider Business Mailing Address
First Line	:	414 N CRAFT HWY
Second Line	:
City	:	CHICKASAW
State	:	AL
Zip	:	36611-1312
Country	:	US
Telephone Number	:	251-452-0531
Fax Number	:	251-456-1529

Provider Business Practice Location Address
First Line	:	414 N CRAFT HWY
Second Line	:
City	:	CHICKASAW
State	:	AL
Zip	:	36611-1312
Country	:	US
Telephone Number	:	251-452-0531
Fax Number	:	251-456-1529

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2016
Last Update Date	:	06/19/2016

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