Healthcare Provider Details

I. General information

NPI: 1235122037
Provider Name (Legal Business Name): DONALD C JACKS R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 09/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56109 VILLAGE CENTER CIRCLE
MATTAWAN MI
49071-8368
US

IV. Provider business mailing address

25696 EMERALD CIR
MATTAWAN MI
49071-7727
US

V. Phone/Fax

Practice location:
  • Phone: 269-668-6801
  • Fax: 269-668-6802
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302029549
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: