Provider Demographics
NPI:1194292060
Name:JACKSON, RYAN (PHARMD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 ROSS ST
Mailing Address - Street 2:
Mailing Address - City:HEFLIN
Mailing Address - State:AL
Mailing Address - Zip Code:36264-1164
Mailing Address - Country:US
Mailing Address - Phone:256-463-2188
Mailing Address - Fax:
Practice Address - Street 1:960 ROSS ST
Practice Address - Street 2:
Practice Address - City:HEFLIN
Practice Address - State:AL
Practice Address - Zip Code:36264-1164
Practice Address - Country:US
Practice Address - Phone:256-463-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist