Provider Demographics
NPI:1669866018
Name:PACK, JON GARY (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:GARY
Last Name:PACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SMELTER AVE NE
Mailing Address - Street 2:PMB 200
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-1958
Mailing Address - Country:US
Mailing Address - Phone:406-453-1380
Mailing Address - Fax:
Practice Address - Street 1:401 NORTHWEST BYP
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-4124
Practice Address - Country:US
Practice Address - Phone:406-453-1380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist