Provider Demographics
NPI:1649592601
Name:JACKSON, DAVID KENNETH (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:KENNETH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLARK AVENUE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406
Mailing Address - Country:US
Mailing Address - Phone:610-491-9700
Mailing Address - Fax:610-354-0800
Practice Address - Street 1:625 CLARK AVENUE
Practice Address - Street 2:SUITE 16
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406
Practice Address - Country:US
Practice Address - Phone:610-491-9700
Practice Address - Fax:610-354-0800
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP438113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist