Provider Demographics
NPI:1992171375
Name:BALUYOT, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BALUYOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 N COLLINS BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3526
Mailing Address - Country:US
Mailing Address - Phone:469-204-6962
Mailing Address - Fax:
Practice Address - Street 1:1977 N COLLINS BLVD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3526
Practice Address - Country:US
Practice Address - Phone:469-204-6962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX420251835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist