Provider Demographics
NPI:1295384451
Name:CHEATHAM-JACKSON, RYAN ELISE (PHARM D)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ELISE
Last Name:CHEATHAM-JACKSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:DR
Other - First Name:RYAN
Other - Middle Name:ELISE
Other - Last Name:CHEATHAM-JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:13821 LORD FAIRFAX PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5914
Mailing Address - Country:US
Mailing Address - Phone:301-938-0082
Mailing Address - Fax:
Practice Address - Street 1:60 SHINING WILLOW WAY
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4224
Practice Address - Country:US
Practice Address - Phone:301-934-5910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26720183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist