Provider Demographics
NPI:1942801238
Name:JACKSON, COLTON (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:COLTON
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 1:500 E HIGHWAY ST # 270
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-4238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E HIGHWAY ST # 270
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-4238
Practice Address - Country:US
Practice Address - Phone:405-350-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist