Provider Demographics
NPI:1215024864
Name:TANNER, JACK ELLIS (RPHR)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ELLIS
Last Name:TANNER
Suffix:
Gender:M
Credentials:RPHR
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:ELLIS
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:PO BOX 285
Mailing Address - Street 2:122 WEST COLLEGE ST
Mailing Address - City:ELLAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31806-0285
Mailing Address - Country:US
Mailing Address - Phone:229-937-9105
Mailing Address - Fax:229-931-9864
Practice Address - Street 1:1206 CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3277
Practice Address - Country:US
Practice Address - Phone:229-931-0271
Practice Address - Fax:229-931-9864
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist