Provider Demographics
NPI:1720684863
Name:JACKSON, JEREMY A (PHARMD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-0372
Mailing Address - Country:US
Mailing Address - Phone:870-561-3113
Mailing Address - Fax:870-561-4291
Practice Address - Street 1:257 S HWY 18 BYPASS
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:870-561-3113
Practice Address - Fax:870-561-4291
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08748183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist