Healthcare Provider Details

I. General information

NPI: 1568909893
Provider Name (Legal Business Name): ROBIN JACKSON PHARM. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 RAYMOND AVENUE
TUPELO MS
38801-3880
US

IV. Provider business mailing address

PO BOX 1671
VERONA MS
38879-1671
US

V. Phone/Fax

Practice location:
  • Phone: 662-810-7732
  • Fax: 662-810-7738
Mailing address:
  • Phone: 662-810-7732
  • Fax: 662-810-7738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberE-09982
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: