Healthcare Provider Details

I. General information

NPI: 1770185035
Provider Name (Legal Business Name): CODY WAYNE JACKSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1193 N MAIN ST
MARION VA
24354-4121
US

IV. Provider business mailing address

PO BOX 665
LEBANON VA
24266-0665
US

V. Phone/Fax

Practice location:
  • Phone: 276-783-6656
  • Fax: 276-783-6769
Mailing address:
  • Phone: 276-701-2965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202210763
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: