Provider Demographics
NPI:1477116465
Name:JACKSON, ROBERT STEVE (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STEVE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:STEVE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:78 N MCCULLOCH BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-4444
Mailing Address - Country:US
Mailing Address - Phone:719-647-9925
Mailing Address - Fax:
Practice Address - Street 1:78 N MCCULLOCH BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-4444
Practice Address - Country:US
Practice Address - Phone:719-647-9925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist