Provider Demographics
NPI:1700210184
Name:JACKSON, IGDALIAH (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:IGDALIAH
Middle Name:
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 1:1207B CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:EDDYSTONE
Mailing Address - State:PA
Mailing Address - Zip Code:19022-1332
Mailing Address - Country:US
Mailing Address - Phone:610-333-0131
Mailing Address - Fax:
Practice Address - Street 1:1207B CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:EDDYSTONE
Practice Address - State:PA
Practice Address - Zip Code:19022-1332
Practice Address - Country:US
Practice Address - Phone:610-333-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP438605183500000X
PARPI0069511835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist