Provider Demographics
NPI:1255758090
Name:CHARLES, JACQUE (PD)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-2131
Mailing Address - Country:US
Mailing Address - Phone:870-295-4100
Mailing Address - Fax:870-295-4102
Practice Address - Street 1:311 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360-2131
Practice Address - Country:US
Practice Address - Phone:870-295-4100
Practice Address - Fax:870-295-4102
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist