Provider Demographics
NPI:1790045763
Name:JACKSON, MICHAEL A
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 532
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:NC
Mailing Address - Zip Code:27850-0532
Mailing Address - Country:US
Mailing Address - Phone:252-586-3414
Mailing Address - Fax:252-586-7377
Practice Address - Street 1:123 EAST SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:NC
Practice Address - Zip Code:27850
Practice Address - Country:US
Practice Address - Phone:252-586-3414
Practice Address - Fax:252-586-7377
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist