Provider Demographics
NPI:1790007748
Name:SKIPPER, JACK T (R PH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:T
Last Name:SKIPPER
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4256
Mailing Address - Country:US
Mailing Address - Phone:803-778-5005
Mailing Address - Fax:803-774-5004
Practice Address - Street 1:240 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4256
Practice Address - Country:US
Practice Address - Phone:803-778-5005
Practice Address - Fax:803-774-5004
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4476183500000X
NC11280183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist