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General NPI Number Information
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NPI Number | 1013443811
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Entity Type | Organization
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Legal Business Name | JACKSON DIABETES CARE AND CONSULTING LLC
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 2610 TRACELAND DR STE A
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City | TUPELO
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State | MS
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Zip | 38801-4237
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Country | US
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Telephone | 662-681-6358
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Fax |
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Provider Business Mailing Address
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Address Line | 2610 TRACELAND DR STE A
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City | TUPELO
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State | MS
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Zip | 38801-4237
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Country | US
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Telephone | 662-681-6358
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | ROBIN L JACKSON
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Credential | PHARMD
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Telephone | 662-304-0181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | E-09982
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License Number State | MS
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