Healthcare Provider Details

I. General information

NPI: 1811075336
Provider Name (Legal Business Name): JACKSON PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W WASHINGTON ST
JACKSON MO
63755-1858
US

IV. Provider business mailing address

200 W WASHINGTON ST
JACKSON MO
63755-1858
US

V. Phone/Fax

Practice location:
  • Phone: 573-243-1303
  • Fax: 573-243-1254
Mailing address:
  • Phone: 314-965-4700
  • Fax: 573-243-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2009003117
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DONALD SCHREIBER
Title or Position: PRESIDENT
Credential:
Phone: 314-965-4700