Provider Demographics
NPI:1699057398
Name:TACKETT, GEORGE (RPH)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:TACKETT
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 1:1008 CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:OH
Mailing Address - Zip Code:44044-1218
Mailing Address - Country:US
Mailing Address - Phone:440-452-4797
Mailing Address - Fax:440-322-9035
Practice Address - Street 1:100 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6138
Practice Address - Country:US
Practice Address - Phone:440-322-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03223121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist