Provider Demographics
NPI:1366032104
Name:ALLEN, JACKSON BRETT (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:BRETT
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927-6932
Mailing Address - Country:US
Mailing Address - Phone:479-675-5341
Mailing Address - Fax:479-675-3400
Practice Address - Street 1:1400 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927-6932
Practice Address - Country:US
Practice Address - Phone:479-675-5341
Practice Address - Fax:479-675-3400
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist