Provider Demographics
NPI:1609113562
Name:JACKSON, AMY ELLIS (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELLIS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 VIRGINIA AVE N
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4227
Mailing Address - Country:US
Mailing Address - Phone:229-386-1171
Mailing Address - Fax:229-516-1885
Practice Address - Street 1:620 VIRGINIA AVE N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4227
Practice Address - Country:US
Practice Address - Phone:229-386-1171
Practice Address - Fax:229-516-1885
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist