Provider Demographics
NPI:1093082901
Name:JACKSON, WENDY MARIE (PHARM D)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 466
Mailing Address - Street 2:108 GRAND AVE
Mailing Address - City:HARRISBURG
Mailing Address - State:SD
Mailing Address - Zip Code:57032-0466
Mailing Address - Country:US
Mailing Address - Phone:712-899-2486
Mailing Address - Fax:800-547-7304
Practice Address - Street 1:1507 W 51ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6648
Practice Address - Country:US
Practice Address - Phone:605-338-7007
Practice Address - Fax:800-547-7304
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-20
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5187183500000X
IA19497183500000X
NE12818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist