Provider Demographics
NPI:1477637841
Name:JACKSON, LONNIE EVERRETT III (PD)
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:EVERRETT
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 WHITE DR
Mailing Address - Street 2:P.O. BOX 2114
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-9467
Mailing Address - Country:US
Mailing Address - Phone:870-698-1974
Mailing Address - Fax:870-698-0141
Practice Address - Street 1:1305 WHITE DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-9467
Practice Address - Country:US
Practice Address - Phone:870-698-1974
Practice Address - Fax:870-698-0141
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0413396OtherNABP#