Provider Demographics
NPI:1528471398
Name:JACKSON, WILLIAM LOUIS (RPH)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LOUIS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2301
Mailing Address - Country:US
Mailing Address - Phone:301-724-5025
Mailing Address - Fax:301-722-6891
Practice Address - Street 1:133 BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2301
Practice Address - Country:US
Practice Address - Phone:301-724-5025
Practice Address - Fax:301-722-6891
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15223183500000X
WVRP0006203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist