Provider Demographics
NPI:1245374776
Name:BESANT, JACK ALBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:ALBERT
Last Name:BESANT
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 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELROY
Mailing Address - State:WI
Mailing Address - Zip Code:53929-1250
Mailing Address - Country:US
Mailing Address - Phone:608-462-8261
Mailing Address - Fax:608-462-8262
Practice Address - Street 1:130 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELROY
Practice Address - State:WI
Practice Address - Zip Code:53929-1250
Practice Address - Country:US
Practice Address - Phone:608-462-8261
Practice Address - Fax:608-462-8262
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8164-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33004800Medicaid
WI33004800Medicaid