Provider Demographics
NPI:1205388162
Name:JACKSON, CHARLES LESLIE (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LESLIE
Last Name:JACKSON
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 1:100 EAST ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-6304
Mailing Address - Country:US
Mailing Address - Phone:870-772-6969
Mailing Address - Fax:870-774-0912
Practice Address - Street 1:100 EAST ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-6304
Practice Address - Country:US
Practice Address - Phone:870-772-6969
Practice Address - Fax:870-774-0912
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD05726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist