Provider Demographics
NPI:1841238300
Name:JACKSON PHARMACY SERVICES
Entity Type:Organization
Organization Name:JACKSON PHARMACY SERVICES
Other - Org Name:PATTERSON DRUGS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-775-7813
Mailing Address - Street 1:22 MULBERRY ST.
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233
Mailing Address - Country:US
Mailing Address - Phone:770-775-7813
Mailing Address - Fax:700-775-7171
Practice Address - Street 1:22 MULBERRY ST.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233
Practice Address - Country:US
Practice Address - Phone:770-775-7813
Practice Address - Fax:700-775-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
GAPHRE0028603336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00520704AMedicaid
GA0622580001Medicare ID - Type Unspecified