Basic Information
| Provider Information | |||||||||
| NPI: | 1326715988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAL | ||||||||
| FirstName: | JORDAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 SHERWOOD LN | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064841944 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 W HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2021 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PCT.0015611 | CT | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.