MEDICARE: MARY LYNNE JACKSON RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	40140	IL

General Provider Information

NPI Number	:	1932747680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LYNNE JACKSON RPH

Provider Business Mailing Address
First Line	:	855 N COMMERCIAL AVE
Second Line	:
City	:	SAINT CLAIR
State	:	MO
Zip	:	63077-1118
Country	:	US
Telephone Number	:	636-629-0710
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 N COMMERCIAL AVE
Second Line	:
City	:	SAINT CLAIR
State	:	MO
Zip	:	63077-1118
Country	:	US
Telephone Number	:	636-629-0710
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2019
Last Update Date	:	12/12/2019

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