Healthcare Provider Details

I. General information

NPI: 1508255423
Provider Name (Legal Business Name): JACKSON COMMUNITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE SUITE 311
JACKSON MS
39213-7681
US

IV. Provider business mailing address

350 WOODROW WILSON AVENUE SUITE 311
JACKSON MS- MISSISSIPPI
39211
UM

V. Phone/Fax

Practice location:
  • Phone: 601-983-1239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRIS MERRIWETHER
Title or Position: MANAGING MEMBER
Credential:
Phone: 601-983-1239