MEDICARE: CHARLES WAYNE JACKSON JR. PHARMACIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	16860	NE

General Provider Information

NPI Number	:	1134739733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WAYNE JACKSON JR. PHARMACIST

Provider Business Mailing Address
First Line	:	2451 N 90TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68134-6009
Country	:	US
Telephone Number	:	402-609-5275
Fax Number	:

Provider Business Practice Location Address
First Line	:	2451 N 90TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68134-6009
Country	:	US
Telephone Number	:	402-609-5275
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2020
Last Update Date	:	08/07/2020

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