Provider Demographics
NPI:1225413560
Name:JACKSON, RICKY ADONIS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:ADONIS
Last Name:JACKSON
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 1:510 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4444
Mailing Address - Country:US
Mailing Address - Phone:318-424-0896
Mailing Address - Fax:
Practice Address - Street 1:510 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4444
Practice Address - Country:US
Practice Address - Phone:318-424-0896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist