Provider Demographics
NPI:1003356734
Name:WINCHESTER, JACK NORMAN (PHARMBS)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:NORMAN
Last Name:WINCHESTER
Suffix:
Gender:M
Credentials:PHARMBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E DATE PL
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4428
Mailing Address - Country:US
Mailing Address - Phone:909-881-4717
Mailing Address - Fax:909-881-4725
Practice Address - Street 1:1717 E DATE PL
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4428
Practice Address - Country:US
Practice Address - Phone:909-881-4717
Practice Address - Fax:909-881-4725
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist