Provider Demographics
NPI:1972890366
Name:HELGESON, JACK ARTHUR (RPH)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:ARTHUR
Last Name:HELGESON
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 1:405 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661
Mailing Address - Country:US
Mailing Address - Phone:208-642-9331
Mailing Address - Fax:208-642-1550
Practice Address - Street 1:405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-3317
Practice Address - Country:US
Practice Address - Phone:208-642-9331
Practice Address - Fax:208-642-1550
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5317183500000X
WAPH00009915183500000X
ORRPH0008024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist