Provider Demographics
NPI:1124173190
Name:JACKSON DISCOUNT DRUG INC
Entity type:Organization
Organization Name:JACKSON DISCOUNT DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-234-2538
Mailing Address - Street 1:1974 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35010-3437
Mailing Address - Country:US
Mailing Address - Phone:256-234-2578
Mailing Address - Fax:256-234-0042
Practice Address - Street 1:1974 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-3437
Practice Address - Country:US
Practice Address - Phone:256-234-2578
Practice Address - Fax:256-234-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6844183500000X
AL1055453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL226027Medicaid
AL100001971Medicaid
AL0110685OtherNABP NCPDP NUMBER