Provider Demographics
NPI:1831493014
Name:PACK, ERNEST
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 GOLDER AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5009
Mailing Address - Country:US
Mailing Address - Phone:432-550-4453
Mailing Address - Fax:432-335-8327
Practice Address - Street 1:319 GOLDER AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5009
Practice Address - Country:US
Practice Address - Phone:432-550-4453
Practice Address - Fax:432-335-8327
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist