Provider Demographics
NPI:1063978260
Name:WANNER, JORDAN RICHARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:RICHARD
Last Name:WANNER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 MIDDLEBRANCH AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-2960
Mailing Address - Country:US
Mailing Address - Phone:330-705-7107
Mailing Address - Fax:
Practice Address - Street 1:4615 MIDDLEBRANCH AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-2960
Practice Address - Country:US
Practice Address - Phone:330-705-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03236378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist