Provider Demographics
NPI:1750630505
Name:JACKSON, TARA (PHARMD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8143 E EARLL DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-5874
Mailing Address - Country:US
Mailing Address - Phone:480-650-1633
Mailing Address - Fax:
Practice Address - Street 1:4353 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-5483
Practice Address - Country:US
Practice Address - Phone:623-435-7197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist