Provider Demographics
NPI:1053151613
Name:TUCKER JORDAN, FARRAH NICOLE
Entity type:Individual
Prefix:
First Name:FARRAH
Middle Name:NICOLE
Last Name:TUCKER JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FARRAH
Other - Middle Name:NICOLE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2706 WELCH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-3350
Mailing Address - Country:US
Mailing Address - Phone:501-773-9300
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHWAY 71 N
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4392
Practice Address - Country:US
Practice Address - Phone:479-394-3897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16896183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist