Provider Demographics
NPI:1760871339
Name:JACKSON COMMUNITY PHARMACY, LLC
Entity Type:Organization
Organization Name:JACKSON COMMUNITY PHARMACY, LLC
Other - Org Name:JACKSON COMMUNITY PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRIWETHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-983-1239
Mailing Address - Street 1:1485 LIVINGSTON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-8004
Mailing Address - Country:US
Mailing Address - Phone:601-983-1239
Mailing Address - Fax:601-982-7103
Practice Address - Street 1:350 W WOODROW WILSON AVE STE 311
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-326-5370
Practice Address - Fax:601-982-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
MSF141583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149725OtherPK