Provider Demographics
NPI:1285611707
Name:JACKSON, EDWARD LAWRENCE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LAWRENCE
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 1:5821 WALDWICK RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-3413
Mailing Address - Country:US
Mailing Address - Phone:910-488-3349
Mailing Address - Fax:
Practice Address - Street 1:WAMC STOP A 2817 REILLY RD
Practice Address - Street 2:MCXC PH
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-8680
Practice Address - Fax:910-907-8443
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110961835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy