Provider Demographics
NPI:1063043248
Name:HERMANN, JACK ROBERT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ROBERT
Last Name:HERMANN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-1303
Mailing Address - Country:US
Mailing Address - Phone:616-514-5602
Mailing Address - Fax:616-247-9875
Practice Address - Street 1:727 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-1303
Practice Address - Country:US
Practice Address - Phone:616-514-5602
Practice Address - Fax:616-247-9875
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist