Provider Demographics
NPI:1326043522
Name:JACKSON'S ROCKY RIDGE PHARMACY, INC
Entity Type:Organization
Organization Name:JACKSON'S ROCKY RIDGE PHARMACY, INC
Other - Org Name:ROCKY RIDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:205-822-5200
Mailing Address - Street 1:3346 MORGAN DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216-3052
Mailing Address - Country:US
Mailing Address - Phone:205-822-5200
Mailing Address - Fax:205-979-3666
Practice Address - Street 1:3346 MORGAN DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35216-3052
Practice Address - Country:US
Practice Address - Phone:205-822-5200
Practice Address - Fax:205-979-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL111519333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003250Medicaid
AL0102018OtherNCPDP
AL0102018OtherNCPDP