Provider Demographics
NPI:1659555290
Name:JACKSON, PAM J (RPH)
Entity Type:Individual
Prefix:MISS
First Name:PAM
Middle Name:J
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 1:300 SE SALEM ST
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:64075-9299
Mailing Address - Country:US
Mailing Address - Phone:816-690-8600
Mailing Address - Fax:816-625-8160
Practice Address - Street 1:300 SE SALEM ST
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:MO
Practice Address - Zip Code:64075-9299
Practice Address - Country:US
Practice Address - Phone:816-690-8600
Practice Address - Fax:816-625-8160
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002008454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist