Provider Demographics
NPI:1346542230
Name:JACKSON, PAULA
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:7595 GREENBELT RD
Mailing Address - Street 2:SAFEWAY PHARMACY
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3403
Mailing Address - Country:US
Mailing Address - Phone:301-345-8777
Mailing Address - Fax:301-220-1217
Practice Address - Street 1:7595 GREENBELT RD
Practice Address - Street 2:SAFEWAY PHARMACY
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3403
Practice Address - Country:US
Practice Address - Phone:301-345-8777
Practice Address - Fax:301-220-1217
Is Sole Proprietor?:No
Enumeration Date:2010-11-26
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12635OtherRPH LICENSE