Provider Demographics
NPI:1427394147
Name:JACKSON, DOUGLAS RAY (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RAY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-3322
Mailing Address - Country:US
Mailing Address - Phone:641-782-8417
Mailing Address - Fax:641-782-6858
Practice Address - Street 1:600 SHELDON ST
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-3322
Practice Address - Country:US
Practice Address - Phone:641-782-8417
Practice Address - Fax:641-782-6858
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16443183500000X
CO11257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist