Provider Demographics
NPI:1710013099
Name:JACKSON, ELLEN GILBERT (RPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:GILBERT
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 1:480 N RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-4737
Mailing Address - Country:US
Mailing Address - Phone:706-638-2981
Mailing Address - Fax:
Practice Address - Street 1:324 PATTON STREET
Practice Address - Street 2:MEDITHRIFT PHARMACY
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728
Practice Address - Country:US
Practice Address - Phone:706-638-3114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16389183500000X
AL9672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist