Provider Demographics
NPI:1477640753
Name:BAKER, JACKIE (RPH)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:BAKER
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 1:4905 N GALLOWAY AVE
Mailing Address - Street 2:APT. 1106
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-7537
Mailing Address - Country:US
Mailing Address - Phone:972-270-1216
Mailing Address - Fax:972-682-3637
Practice Address - Street 1:300 W VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-5566
Practice Address - Country:US
Practice Address - Phone:432-263-7360
Practice Address - Fax:432-268-5019
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist