Provider Demographics
NPI:1396756961
Name:KATE POWELL JORDAN
Entity type:Organization
Organization Name:KATE POWELL JORDAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:251-275-1000
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:GROVE HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36451-0069
Mailing Address - Country:US
Mailing Address - Phone:251-275-1000
Mailing Address - Fax:
Practice Address - Street 1:126 MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3144
Practice Address - Country:US
Practice Address - Phone:251-275-1000
Practice Address - Fax:251-275-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1110463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002866Medicaid
1993922OtherPK
AL100002866Medicaid