Provider Demographics
NPI:1811353626
Name:CHARLES, JILL
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47390-1434
Mailing Address - Country:US
Mailing Address - Phone:765-964-6000
Mailing Address - Fax:765-964-6017
Practice Address - Street 1:106 S COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:IN
Practice Address - Zip Code:47390-1434
Practice Address - Country:US
Practice Address - Phone:765-964-6000
Practice Address - Fax:765-964-6017
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016873A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist