Provider Demographics
NPI:1992001267
Name:JACO, CHARLES RUSSELL (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RUSSELL
Last Name:JACO
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 1:510 BOTLEY CT APT 306
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8239
Mailing Address - Country:US
Mailing Address - Phone:803-459-6157
Mailing Address - Fax:
Practice Address - Street 1:510 BOTLEY CT APT 306
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-459-6157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist