Provider Demographics
NPI:1528108677
Name:JACKSONS DRUGS OF MONTICELLO, INC.
Entity type:Organization
Organization Name:JACKSONS DRUGS OF MONTICELLO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:850-948-3011
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32331-0129
Mailing Address - Country:US
Mailing Address - Phone:850-948-3011
Mailing Address - Fax:850-948-3778
Practice Address - Street 1:1308 SW GRAND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:FL
Practice Address - Zip Code:32331
Practice Address - Country:US
Practice Address - Phone:850-948-3011
Practice Address - Fax:850-948-3778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH125053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102475200Medicaid