Provider Demographics
NPI:1063625184
Name:JACKSON, TARA SAULS (PHARMD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:SAULS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 ELAM CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SHELLMAN
Mailing Address - State:GA
Mailing Address - Zip Code:39886-2107
Mailing Address - Country:US
Mailing Address - Phone:229-849-4101
Mailing Address - Fax:
Practice Address - Street 1:412 JOHNSON ST SE
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:GA
Practice Address - Zip Code:39842-1523
Practice Address - Country:US
Practice Address - Phone:229-995-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH020862OtherSTATE LICENSE