Provider Demographics
NPI:1063143543
Name:JACK, SAVANNAH MORGAN
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:MORGAN
Last Name:JACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ENTERPRISE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405
Mailing Address - Country:US
Mailing Address - Phone:304-263-4185
Mailing Address - Fax:
Practice Address - Street 1:400 ENTERPRISE CIRCLE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405
Practice Address - Country:US
Practice Address - Phone:304-263-4185
Practice Address - Fax:304-264-5953
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT0011028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist