Healthcare Provider Details

I. General information

NPI: 1184640369
Provider Name (Legal Business Name): JACKSON DRUG CO., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10077 COMMERCE ST
SUMMERVILLE GA
30747-1356
US

IV. Provider business mailing address

PO BOX 120
SUMMERVILLE GA
30747-0120
US

V. Phone/Fax

Practice location:
  • Phone: 706-857-2731
  • Fax: 706-857-1773
Mailing address:
  • Phone: 706-857-2731
  • Fax: 706-857-1773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE004184
License Number StateGA

VIII. Authorized Official

Name: MR. JAMES ROBERT JACKSON
Title or Position: PRES
Credential: RPH
Phone: 706-857-2731