Provider Demographics
NPI:1497061063
Name:WEST, JACK (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WEST
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 1:103 W ALLEGHENY RD
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:PA
Mailing Address - Zip Code:15126-9779
Mailing Address - Country:US
Mailing Address - Phone:724-695-7317
Mailing Address - Fax:
Practice Address - Street 1:103 W ALLEGHENY RD
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:PA
Practice Address - Zip Code:15126-9779
Practice Address - Country:US
Practice Address - Phone:724-695-7317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP035521L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist