Provider Demographics
NPI:1710985783
Name:JACKSON, VINCENT EUGENE (PHARM D, RPH)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:EUGENE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 MADELINE DR
Mailing Address - Street 2:
Mailing Address - City:ST LEONARD
Mailing Address - State:MD
Mailing Address - Zip Code:20685-2567
Mailing Address - Country:US
Mailing Address - Phone:301-580-3818
Mailing Address - Fax:410-535-8307
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:PHARMACY DEPARTMENT
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4017
Practice Address - Country:US
Practice Address - Phone:410-535-4000
Practice Address - Fax:410-535-8307
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD154531835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy