Provider Demographics
NPI:1992003594
Name:JACKSON, TRACY ELAINE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2505
Mailing Address - Country:US
Mailing Address - Phone:803-773-7302
Mailing Address - Fax:
Practice Address - Street 1:1000 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2505
Practice Address - Country:US
Practice Address - Phone:803-773-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-05
Last Update Date:2011-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist