Provider Demographics
NPI:1053432203
Name:MOHR, JACK THOMAS (PHARMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:THOMAS
Last Name:MOHR
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 1:15374 SUNSET HILL DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7125
Mailing Address - Country:US
Mailing Address - Phone:218-847-9183
Mailing Address - Fax:
Practice Address - Street 1:PHS INDIAN HEALTH SERVICE
Practice Address - Street 2:40520 CO. HWY 34
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569
Practice Address - Country:US
Practice Address - Phone:218-983-6375
Practice Address - Fax:218-983-6384
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4822183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist