Provider Demographics
NPI:1386924348
Name:BACON, JONATHAN MARK (RPH)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:MARK
Last Name:BACON
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 1:701 ROYAL CT
Mailing Address - Street 2:APT # 705
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2748
Mailing Address - Country:US
Mailing Address - Phone:704-516-5219
Mailing Address - Fax:
Practice Address - Street 1:1533 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4723
Practice Address - Country:US
Practice Address - Phone:704-342-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist