Provider Demographics
NPI:1306145867
Name:JACKSON, MIRANDA HULETT (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:HULETT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 CAMPBELL LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1040
Mailing Address - Country:US
Mailing Address - Phone:270-843-2383
Mailing Address - Fax:270-783-8687
Practice Address - Street 1:711 CAMPBELL LN
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1040
Practice Address - Country:US
Practice Address - Phone:270-843-2383
Practice Address - Fax:270-783-8687
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014548183500000X
TN0000033743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist