Healthcare Provider Details

I. General information

NPI: 1477668416
Provider Name (Legal Business Name): JACKSON CLINIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 W FOREST AVE
JACKSON TN
38301-3902
US

IV. Provider business mailing address

616 W FOREST AVE
JACKSON TN
38301-3902
US

V. Phone/Fax

Practice location:
  • Phone: 731-422-0232
  • Fax: 731-422-0389
Mailing address:
  • Phone: 731-422-0232
  • Fax: 731-422-0389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number454
License Number StateTN

VIII. Authorized Official

Name: DARLENE PATTON
Title or Position: PHCY DIR
Credential: DPH
Phone: 731-422-0232