Provider Demographics
NPI:1942614748
Name:JACKSON, ANTHONY (PHARM D)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 ELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-2621
Mailing Address - Country:US
Mailing Address - Phone:415-845-6917
Mailing Address - Fax:661-725-3645
Practice Address - Street 1:1017 ELLINGTON ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2621
Practice Address - Country:US
Practice Address - Phone:415-845-6917
Practice Address - Fax:661-725-3645
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404981835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist