Healthcare Provider Details

I. General information

NPI: 1699422014
Provider Name (Legal Business Name): MELISSA LYNN JACKSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2022
Last Update Date: 03/05/2022
Certification Date: 03/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ELM ST
LUDLOW KY
41016-1494
US

IV. Provider business mailing address

130 ELM ST # 1
LUDLOW KY
41016-1494
US

V. Phone/Fax

Practice location:
  • Phone: 859-261-2210
  • Fax:
Mailing address:
  • Phone: 859-261-2210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number022091
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: