Provider Demographics
NPI:1033671474
Name:WITT, JACKSON DOUGLAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:DOUGLAS
Last Name:WITT
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 1:218 ALLEN CIR
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-5212
Mailing Address - Country:US
Mailing Address - Phone:256-668-3543
Mailing Address - Fax:
Practice Address - Street 1:13675 HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-2831
Practice Address - Country:US
Practice Address - Phone:256-332-7394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist