Provider Demographics
NPI:1811170293
Name:JACKSON, GREGORY EMORY (RPH)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:EMORY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 W 30 STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:646-968-4689
Mailing Address - Fax:646-968-4690
Practice Address - Street 1:526 W 30TH STREET
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:646-968-4689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-09
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist