Provider Demographics
NPI:1740605906
Name:HALL, JACK BRIAN I (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:BRIAN
Last Name:HALL
Suffix:I
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 1:3360 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-6487
Mailing Address - Country:US
Mailing Address - Phone:318-435-9011
Mailing Address - Fax:
Practice Address - Street 1:3360 FRONT ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-6487
Practice Address - Country:US
Practice Address - Phone:318-435-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist