Provider Demographics
NPI:1437436714
Name:CARSON, JACQUELINE MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:CARSON
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 1:11780 GREEN BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9497
Mailing Address - Country:US
Mailing Address - Phone:330-702-1842
Mailing Address - Fax:
Practice Address - Street 1:5501 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2316
Practice Address - Country:US
Practice Address - Phone:330-792-4785
Practice Address - Fax:330-792-6407
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03124800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH248422OtherNABP