Provider Demographics
NPI:1265718746
Name:JACKSON, AMANDA MARCONI (PHARMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARCONI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 CHARLESWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-1839
Mailing Address - Country:US
Mailing Address - Phone:870-702-1004
Mailing Address - Fax:
Practice Address - Street 1:1800 N MISSOURI ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-1791
Practice Address - Country:US
Practice Address - Phone:870-735-8987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09886183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist