Provider Demographics
NPI:1295341097
Name:JACKSON, PATRICK DALE (PHARM D)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:DALE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 N GOWER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-4009
Mailing Address - Country:US
Mailing Address - Phone:213-924-5006
Mailing Address - Fax:
Practice Address - Street 1:19300 S HAMILTON AVE STE 170-180
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4400
Practice Address - Country:US
Practice Address - Phone:310-464-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist