Provider Demographics
NPI:1457477598
Name:ALLEN, JACK A (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7013 E CHICKADEE CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-0932
Mailing Address - Country:US
Mailing Address - Phone:520-615-2215
Mailing Address - Fax:
Practice Address - Street 1:3675 E BRITANNIA DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-5041
Practice Address - Country:US
Practice Address - Phone:520-209-3000
Practice Address - Fax:520-209-3040
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist