Provider Demographics
NPI:1790547701
Name:JACKSON PHARMACY INC
Entity Type:Organization
Organization Name:JACKSON PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-965-4700
Mailing Address - Street 1:755 S NEW BALLAS RD STE 260
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8744
Mailing Address - Country:US
Mailing Address - Phone:314-965-4700
Mailing Address - Fax:314-965-4706
Practice Address - Street 1:200 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-1858
Practice Address - Country:US
Practice Address - Phone:573-243-1303
Practice Address - Fax:573-243-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy