Provider Demographics
NPI:1225446172
Name:JACKSON, ROBERT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
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 1:1557 1/2 REED AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5361
Mailing Address - Country:US
Mailing Address - Phone:619-400-7061
Mailing Address - Fax:
Practice Address - Street 1:13487 CAMINO CANADA
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-8811
Practice Address - Country:US
Practice Address - Phone:619-561-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69796183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist