Provider Demographics
NPI:1124371257
Name:QUICK, JACKSON (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:QUICK
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 1:1947 BLUEGRASS CIR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7355
Mailing Address - Country:US
Mailing Address - Phone:307-635-3712
Mailing Address - Fax:307-433-8229
Practice Address - Street 1:1947 BLUEGRASS CIR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7355
Practice Address - Country:US
Practice Address - Phone:307-635-3712
Practice Address - Fax:307-433-8229
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist