Healthcare Provider Details

I. General information

NPI: 1326043522
Provider Name (Legal Business Name): JACKSON'S ROCKY RIDGE PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3346 MORGAN DR
BIRMINGHAM AL
35216-3052
US

IV. Provider business mailing address

3346 MORGAN DR
BIRMINGHAM AL
35216-3052
US

V. Phone/Fax

Practice location:
  • Phone: 205-822-5200
  • Fax: 205-979-3666
Mailing address:
  • Phone: 205-822-5200
  • Fax: 205-979-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number111519
License Number StateAL

VIII. Authorized Official

Name: DR. BRAD F JACKSON
Title or Position: PRESIDENT
Credential: PHARM D
Phone: 205-822-5200