Provider Demographics
NPI:1235122037
Name:JACKS, DONALD C (RPH)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:C
Last Name:JACKS
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 1:25696 EMERALD CIR
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-7727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56109 VILLAGE CENTER CIRCLE
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-8368
Practice Address - Country:US
Practice Address - Phone:269-668-6801
Practice Address - Fax:269-668-6802
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist