Provider Demographics
NPI:1093309965
Name:WOOD, JACKSON (RPH)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 WADSWORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-3302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4401 WADSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-3302
Practice Address - Country:US
Practice Address - Phone:303-463-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0023369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist