Provider Demographics
NPI:1235975541
Name:ANDERSON, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-229 LOULULELO PL
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94-1480 MOANIANI ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-4632
Practice Address - Country:US
Practice Address - Phone:833-833-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-5027183500000X
AZS025967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist