MEDICARE: MR. DONALD C JACKS R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302029549	MI

General Provider Information

NPI Number	:	1235122037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD C JACKS R.PH.

Provider Business Mailing Address
First Line	:	25696 EMERALD CIR
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-7727
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	56109 VILLAGE CENTER CIRCLE
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-8368
Country	:	US
Telephone Number	:	269-668-6801
Fax Number	:	269-668-6802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	09/15/2009

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