Provider Demographics
NPI:1093025892
Name:WELLS, JACK R JR (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:WELLS
Suffix:JR
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 1:10745 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-3069
Mailing Address - Country:US
Mailing Address - Phone:317-852-0869
Mailing Address - Fax:
Practice Address - Street 1:10745 EAGLE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-3069
Practice Address - Country:US
Practice Address - Phone:317-852-0869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018395A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist