Healthcare Provider Details

I. General information

NPI: 1477637841
Provider Name (Legal Business Name): LONNIE EVERRETT JACKSON III P.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WHITE DR
BATESVILLE AR
72501-9467
US

IV. Provider business mailing address

1305 WHITE DR P.O. BOX 2114
BATESVILLE AR
72501-9467
US

V. Phone/Fax

Practice location:
  • Phone: 870-698-1974
  • Fax: 870-698-0141
Mailing address:
  • Phone: 870-698-1974
  • Fax: 870-698-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD06643
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: