Provider Demographics
NPI:1932446887
Name:JACK, DEXTER E (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:E
Last Name:JACK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 DALLAS HWY SW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2567
Mailing Address - Country:US
Mailing Address - Phone:770-426-3256
Mailing Address - Fax:
Practice Address - Street 1:2500 DALLAS HWY SW
Practice Address - Street 2:SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2567
Practice Address - Country:US
Practice Address - Phone:770-426-3256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist