Provider Demographics
NPI:1386474179
Name:JACKSON, SYDNEY MICHAEL EMILY (RPH)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:MICHAEL EMILY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6008
Mailing Address - Country:US
Mailing Address - Phone:207-797-0536
Mailing Address - Fax:
Practice Address - Street 1:91 AUBURN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6008
Practice Address - Country:US
Practice Address - Phone:207-797-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR72139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist