Provider Demographics
NPI:1659879914
Name:JACKSON, NICOLE C (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-1249 MEHEULA PKWY STE D
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-1779
Mailing Address - Country:US
Mailing Address - Phone:808-625-5222
Mailing Address - Fax:
Practice Address - Street 1:95-1249 MEHEULA PKWY
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1779
Practice Address - Country:US
Practice Address - Phone:808-625-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-4207183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist