Provider Demographics
NPI:1205279262
Name:NEILL, JACKLYN (RPH)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:NEILL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2414
Mailing Address - Country:US
Mailing Address - Phone:970-641-6379
Mailing Address - Fax:970-641-6839
Practice Address - Street 1:880 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2414
Practice Address - Country:US
Practice Address - Phone:970-641-6379
Practice Address - Fax:970-641-6839
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist