Provider Demographics
NPI:1306120399
Name:JACK, RICHARD L (RPH)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:JACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:1214 N LAKE HURON SHORE DRIVE
Mailing Address - City:HARRISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48740-0368
Mailing Address - Country:US
Mailing Address - Phone:989-724-6457
Mailing Address - Fax:
Practice Address - Street 1:903 N MISSION ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-1001
Practice Address - Country:US
Practice Address - Phone:989-772-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist