Provider Demographics
NPI:1316396492
Name:MILLER, JACKIE S (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:S
Last Name:MILLER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-2320
Mailing Address - Country:US
Mailing Address - Phone:386-676-7126
Mailing Address - Fax:
Practice Address - Street 1:1340 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-2320
Practice Address - Country:US
Practice Address - Phone:386-676-7126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS21021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist