Provider Demographics
NPI:1609466689
Name:JUSTUS, JACKSON (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:JUSTUS
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 1:213 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-1707
Mailing Address - Country:US
Mailing Address - Phone:641-437-7200
Mailing Address - Fax:641-437-7300
Practice Address - Street 1:213 N 13TH ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1707
Practice Address - Country:US
Practice Address - Phone:641-437-7200
Practice Address - Fax:641-437-7300
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202217164183500000X
IA24043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist