Provider Demographics
NPI:1891217345
Name:CUNNINGHAM, JACK BARRETT III (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BARRETT
Last Name:CUNNINGHAM
Suffix:III
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BOONE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-5004
Mailing Address - Country:US
Mailing Address - Phone:276-345-6283
Mailing Address - Fax:
Practice Address - Street 1:240 SHADOWLINE DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5088
Practice Address - Country:US
Practice Address - Phone:828-264-4751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-15
Last Update Date:2017-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist