Healthcare Provider Details

I. General information

NPI: 1043262488
Provider Name (Legal Business Name): JACKSON HOSPITAL & CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 PINE ST DEPARTMENT OF PHARMACY
MONTGOMERY AL
36106-1109
US

IV. Provider business mailing address

1725 PINE STREET
MONTGOMERY AL
36106-1103
US

V. Phone/Fax

Practice location:
  • Phone: 334-293-8780
  • Fax: 334-293-8791
Mailing address:
  • Phone: 334-293-8000
  • Fax: 334-293-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number140004
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2162053
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberPA88
License Number StateAL

VIII. Authorized Official

Name: RICHARD F MANN
Title or Position: PRESIDENT
Credential:
Phone: 334-293-8820