Provider Demographics
NPI:1831317528
Name:JACKSON, TERESA B (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 GREENHILL DR
Mailing Address - Street 2:
Mailing Address - City:PFAFFTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27040-9557
Mailing Address - Country:US
Mailing Address - Phone:336-758-5218
Mailing Address - Fax:336-758-6054
Practice Address - Street 1:LOWER LEVEL REYNOLDS GYM WINGATE ROAD
Practice Address - Street 2:LOWER LEVEL REYNOLDS GYM WINGATE ROAD
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27109
Practice Address - Country:US
Practice Address - Phone:336-758-5218
Practice Address - Fax:336-758-6054
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist