Provider Demographics
NPI:1568669208
Name:JACKSON'S DISCOUNT PHARMACY, INC.
Entity Type:Organization
Organization Name:JACKSON'S DISCOUNT PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-832-8000
Mailing Address - Street 1:11340 THREE RIVERS RD STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3650
Mailing Address - Country:US
Mailing Address - Phone:228-832-0808
Mailing Address - Fax:
Practice Address - Street 1:11340 THREE RIVERS RD STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3650
Practice Address - Country:US
Practice Address - Phone:228-832-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS022640113336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440464Medicaid
MS0741110001Medicare NSC