Provider Demographics
NPI:1235388398
Name:JACKSON, KRISTIAN B (RPH)
Entity Type:Individual
Prefix:MR
First Name:KRISTIAN
Middle Name:B
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:ME
Mailing Address - Zip Code:04668-0097
Mailing Address - Country:US
Mailing Address - Phone:207-796-2321
Mailing Address - Fax:
Practice Address - Street 1:401 PETER DANA POINT RD
Practice Address - Street 2:
Practice Address - City:INDIAN TWP
Practice Address - State:ME
Practice Address - Zip Code:04668-5007
Practice Address - Country:US
Practice Address - Phone:207-796-2321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40346183500000X
MEPR5291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist