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General NPI Number Information
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NPI Number | 1306120399
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Entity Type | Individual
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Provider Name | RICHARD L JACK RPH
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Gender | Male
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Dates
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Enumeration Date | 10/07/2011
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Last Update Date | 10/07/2011
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Provider Practice Location Address
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Address Line | 903 N MISSION ST
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City | MT PLEASANT
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State | MI
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Zip | 48858-1001
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Country | US
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Telephone | 989-772-0291
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 368 1214 N LAKE HURON SHORE DRIVE
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City | HARRISVILLE
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State | MI
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Zip | 48740-0368
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Country | US
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Telephone | 989-724-6457
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5302020357
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License Number State | MI
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