Provider Demographics
NPI:1831228618
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:PHARMACIST IN CHARGE NOAH
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY HUNDERUP
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:731-664-8046
Mailing Address - Street 1:2863 HIGHWAY 45 BYP
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3618
Mailing Address - Country:US
Mailing Address - Phone:731-664-8046
Mailing Address - Fax:731-660-8339
Practice Address - Street 1:2863 HIGHWAY 45 BYP
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3618
Practice Address - Country:US
Practice Address - Phone:731-664-8046
Practice Address - Fax:731-660-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336C0004X
TN29873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2091766OtherPK