Provider Demographics
NPI:1063865756
Name:JABCON, MARY (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JABCON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 B DR N
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-8367
Mailing Address - Country:US
Mailing Address - Phone:269-979-4727
Mailing Address - Fax:
Practice Address - Street 1:6020 B DR N
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-8367
Practice Address - Country:US
Practice Address - Phone:269-979-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI532024254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist