Provider Demographics
NPI:1326084831
Name:JACKSONS DISCOUNT PHARMACY INC
Entity Type:Organization
Organization Name:JACKSONS DISCOUNT PHARMACY INC
Other - Org Name:JACKSONS DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:228-832-8000
Mailing Address - Street 1:11340 THREE RIVERS RD
Mailing Address - Street 2:STE A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3660
Mailing Address - Country:US
Mailing Address - Phone:228-832-8000
Mailing Address - Fax:228-832-0808
Practice Address - Street 1:11340 THREE RIVERS RD
Practice Address - Street 2:STE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3660
Practice Address - Country:US
Practice Address - Phone:228-832-8000
Practice Address - Fax:228-832-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS02264/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045339OtherPK
MS00030343Medicaid
0741110001Medicare NSC