Provider Demographics
NPI:1679852842
Name:JACKSON, ROBERT L (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 RED CEDAR CT SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-4293
Mailing Address - Country:US
Mailing Address - Phone:770-279-0609
Mailing Address - Fax:
Practice Address - Street 1:3650 STEVE REYNOLDS BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4506
Practice Address - Country:US
Practice Address - Phone:770-931-6066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0222491835P0018X
FL228701835P0018X
CA417421835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist