Healthcare Provider Details

I. General information

NPI: 1538278478
Provider Name (Legal Business Name): MICHAEL W. JACKSON, A SOLE PROPRIETOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E COLUMBIA ST
SAN AUGUSTINE TX
75972-1902
US

IV. Provider business mailing address

104 E COLUMBIA ST
SAN AUGUSTINE TX
75972-1902
US

V. Phone/Fax

Practice location:
  • Phone: 936-275-3401
  • Fax: 936-275-3450
Mailing address:
  • Phone: 936-275-3401
  • Fax: 936-275-3450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number13848
License Number StateTX

VIII. Authorized Official

Name: MICHAEL W JACKSON
Title or Position: OWNER
Credential:
Phone: 936-275-3401