Provider Demographics
NPI:1851171730
Name:JACKSON, RICHARD (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1202
Mailing Address - Country:US
Mailing Address - Phone:610-574-9186
Mailing Address - Fax:
Practice Address - Street 1:338 MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:MERION STATION
Practice Address - State:PA
Practice Address - Zip Code:19066-1202
Practice Address - Country:US
Practice Address - Phone:610-664-4815
Practice Address - Fax:610-664-5854
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP041566L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist