Provider Demographics
NPI:1720068232
Name:EATON, JACK H (RPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:H
Last Name:EATON
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 1:176 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211
Mailing Address - Country:US
Mailing Address - Phone:718-855-3070
Mailing Address - Fax:718-596-4657
Practice Address - Street 1:176 LEE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211
Practice Address - Country:US
Practice Address - Phone:718-855-3070
Practice Address - Fax:718-596-4657
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0238781183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00263410Medicaid
3326673OtherNABP
NY023878OtherPHARMACIST LICENSE
440273001Medicare ID - Type Unspecified