Provider Demographics
NPI:1619222809
Name:JACKSON, CYNTHIA MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15891 STATE ROUTE 170
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-8604
Mailing Address - Country:US
Mailing Address - Phone:330-386-6666
Mailing Address - Fax:330-385-8912
Practice Address - Street 1:15891 STATE ROUTE 170
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9415
Practice Address - Country:US
Practice Address - Phone:330-386-6666
Practice Address - Fax:330-385-8912
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist