Provider Demographics
NPI:1538278478
Name:MICHAEL W. JACKSON, A SOLE PROPRIETOR
Entity type:Organization
Organization Name:MICHAEL W. JACKSON, A SOLE PROPRIETOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-275-3401
Mailing Address - Street 1:104 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN AUGUSTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75972-1902
Mailing Address - Country:US
Mailing Address - Phone:936-275-3401
Mailing Address - Fax:936-275-3450
Practice Address - Street 1:104 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-1902
Practice Address - Country:US
Practice Address - Phone:936-275-3401
Practice Address - Fax:936-275-3450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX138483336C0003X, 332BC3200X, 332BP3500X, 332BX2000X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherCHAMPUS/TRICARE
1009000001Medicare NSC
=========0001OtherTRICARE DME
TX750567OtherBCBS-IV
TX519613OtherBCBS (NON-IV)
5081450001Medicare NSC