Provider Demographics
NPI:1104413376
Name:RECTOR, JACK LOUIS (DPH)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:LOUIS
Last Name:RECTOR
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:LOUIS
Other - Last Name:RECTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2115 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-5327
Mailing Address - Country:US
Mailing Address - Phone:918-786-4491
Mailing Address - Fax:918-786-2043
Practice Address - Street 1:2115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5327
Practice Address - Country:US
Practice Address - Phone:918-786-4491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist