Provider Demographics
NPI:1588987960
Name:JACKSON, KIRK GORDON (RPH)
Entity type:Individual
Prefix:MR
First Name:KIRK
Middle Name:GORDON
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 1:7923 E. MCDOWELL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257
Mailing Address - Country:US
Mailing Address - Phone:480-874-9830
Mailing Address - Fax:480-941-3961
Practice Address - Street 1:7923 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3747
Practice Address - Country:US
Practice Address - Phone:480-874-9830
Practice Address - Fax:480-941-3961
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS009706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist