Provider Demographics
NPI:1932112711
Name:JACKSON, MICHAEL ALLAN (BS PHARMACY)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-1114
Mailing Address - Country:US
Mailing Address - Phone:850-222-2400
Mailing Address - Fax:850-561-6758
Practice Address - Street 1:610 N ADAMS ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-1114
Practice Address - Country:US
Practice Address - Phone:850-222-2400
Practice Address - Fax:850-561-6758
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS17960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10024OtherPHARMACIST LICENSE NUMBER
FLPU3331OtherPHARMACIST CONSULTANT LIC
FLPS17960OtherPHARMACIST LICENSE NUMBER