Provider Demographics
NPI:1669847828
Name:JACKSON, WILTON JR
Entity Type:Individual
Prefix:
First Name:WILTON
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N WILKINSON DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384-1249
Mailing Address - Country:US
Mailing Address - Phone:910-308-6499
Mailing Address - Fax:
Practice Address - Street 1:3003 FAYETTEVILLE RD
Practice Address - Street 2:WALGREENS #1056
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358
Practice Address - Country:US
Practice Address - Phone:910-739-7072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist