Provider Demographics
NPI:1093302077
Name:JACKSON, BLAIR ROLLINGS
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:ROLLINGS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7023 THREE CHOPT RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3606
Mailing Address - Country:US
Mailing Address - Phone:804-285-4449
Mailing Address - Fax:
Practice Address - Street 1:7023 THREE CHOPT RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3606
Practice Address - Country:US
Practice Address - Phone:804-285-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202213161333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy