Healthcare Provider Details

I. General information

NPI: 1205943057
Provider Name (Legal Business Name): JACKSONS DRUGS OF MONTICELLO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 E DOGWOOD ST
MONTICELLO FL
32344-1928
US

IV. Provider business mailing address

PO BOX 338
MONTICELLO FL
32345-0338
US

V. Phone/Fax

Practice location:
  • Phone: 850-997-3553
  • Fax: 850-342-3578
Mailing address:
  • Phone: 850-997-3553
  • Fax: 850-342-3578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH1023
License Number StateFL

VIII. Authorized Official

Name: MR. CHARLES L JACKSON
Title or Position: PRESIDENT
Credential: RPH
Phone: 850-997-3553