Provider Demographics
NPI:1881927192
Name:JACKSON'S ROCKY RIDGE PHARMACY, INC
Entity type:Organization
Organization Name:JACKSON'S ROCKY RIDGE PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:205-822-5200
Mailing Address - Street 1:2108 GATEWAY DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-6886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3346 MORGAN DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35216-3052
Practice Address - Country:US
Practice Address - Phone:205-822-5200
Practice Address - Fax:205-979-3666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON'S ROCKY RIDGE PHARMACY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPENDING NPI APPROVAL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-40811OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL0102018OtherNCPDP
AL100003250Medicaid
AL100003250Medicaid
AL5721890001Medicare NSC