Provider Demographics
NPI:1568064491
Name:JACKSON APOTHECARY, LLC
Entity Type:Organization
Organization Name:JACKSON APOTHECARY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:205-422-8114
Mailing Address - Street 1:3633 ALTADENA DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2229
Mailing Address - Country:US
Mailing Address - Phone:205-422-8114
Mailing Address - Fax:
Practice Address - Street 1:12755 HWY 22E
Practice Address - Street 2:
Practice Address - City:NEW SITE
Practice Address - State:AL
Practice Address - Zip Code:36256-3625
Practice Address - Country:US
Practice Address - Phone:205-422-8114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy