Healthcare Provider Details

I. General information

NPI: 1558374967
Provider Name (Legal Business Name): WILL DAVID JACKS II PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 ROSS ST
HEFLIN AL
36264-1131
US

IV. Provider business mailing address

875 ROSS ST
HEFLIN AL
36264-1131
US

V. Phone/Fax

Practice location:
  • Phone: 256-463-2197
  • Fax: 256-463-2306
Mailing address:
  • Phone: 256-463-2197
  • Fax: 256-463-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15073
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: