=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457849952
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES ANTHONY JINKS RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2018
-----------------------------------------------------
Last Update Date | 04/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1260 E STATE ROAD 205
-----------------------------------------------------
City | COLUMBIA CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46725-9492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-248-9520
-----------------------------------------------------
Fax | 260-248-9134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 EMS B6C LN
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46538-8969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-416-6620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26016649A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------