Provider Demographics
NPI:1477668416
Name:JACKSON CLINIC PHARMACY INC
Entity type:Organization
Organization Name:JACKSON CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHCY DIR
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:731-422-0232
Mailing Address - Street 1:616 W FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3902
Mailing Address - Country:US
Mailing Address - Phone:731-422-0232
Mailing Address - Fax:731-422-0389
Practice Address - Street 1:616 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3902
Practice Address - Country:US
Practice Address - Phone:731-422-0232
Practice Address - Fax:731-422-0389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336S0011X, 3336C0003X
TN4543336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095588OtherPK