Provider Demographics
NPI:1003035973
Name:JACKSON, MELISSA J (RPH)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1156
Mailing Address - Country:US
Mailing Address - Phone:989-386-2317
Mailing Address - Fax:989-386-4505
Practice Address - Street 1:1509 N MCEWAN ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1113
Practice Address - Country:US
Practice Address - Phone:989-386-7721
Practice Address - Fax:989-386-4505
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist