Provider Demographics
NPI:1558973115
Name:JACKSON, BRIAN LEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 NORTHPOINTE PKWY APT 316
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-1606
Mailing Address - Country:US
Mailing Address - Phone:228-209-4624
Mailing Address - Fax:
Practice Address - Street 1:5780 TERRY RD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-9745
Practice Address - Country:US
Practice Address - Phone:601-346-2553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-12966183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist