Provider Demographics
NPI:1376146274
Name:JACKSON, MEYONCA (PHARMD,)
Entity Type:Individual
Prefix:
First Name:MEYONCA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 WYNCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8020
Mailing Address - Country:US
Mailing Address - Phone:404-993-4068
Mailing Address - Fax:
Practice Address - Street 1:1045 SOUTHCREST DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6113
Practice Address - Country:US
Practice Address - Phone:678-289-0549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0315361835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GANAOtherNA