Provider Demographics
NPI:1790327674
Name:JACKSON, WILEY (RPH)
Entity Type:Individual
Prefix:
First Name:WILEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 WILDROSE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-8681
Mailing Address - Country:US
Mailing Address - Phone:336-404-0786
Mailing Address - Fax:
Practice Address - Street 1:215 PIEDMONT PL
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4176
Practice Address - Country:US
Practice Address - Phone:434-797-3439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202013051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist