Provider Demographics
NPI:1306928312
Name:AVERYT, JACK D JR (RPH)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:D
Last Name:AVERYT
Suffix:JR
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 1:850 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6552
Mailing Address - Country:US
Mailing Address - Phone:254-526-9220
Mailing Address - Fax:254-699-1134
Practice Address - Street 1:2500 CROSS DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5256
Practice Address - Country:US
Practice Address - Phone:254-699-1133
Practice Address - Fax:254-699-1134
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist