Provider Demographics
NPI:1912906736
Name:JACKSON, STEVEN L (RPH)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:L
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 1:2256 W NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-9415
Mailing Address - Country:US
Mailing Address - Phone:850-478-4450
Mailing Address - Fax:850-478-4842
Practice Address - Street 1:2256 W NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-9415
Practice Address - Country:US
Practice Address - Phone:850-478-4450
Practice Address - Fax:850-478-4842
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19736183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101036100Medicaid