Provider Demographics
NPI:1942664974
Name:JACK, DAVID (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:JACK
Suffix:
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 1:130 ENTERPRISE DR
Mailing Address - Street 2:WALGREENS SPECIALTY PHARMACY
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15275-1213
Mailing Address - Country:US
Mailing Address - Phone:412-413-8041
Mailing Address - Fax:877-231-8302
Practice Address - Street 1:130 ENTERPRISE DR
Practice Address - Street 2:WALGREENS SPECIALTY PHARMACY
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15275-1213
Practice Address - Country:US
Practice Address - Phone:412-413-8041
Practice Address - Fax:877-231-8302
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP033586L183500000X
WVRP0008819183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist