MEDICARE: JACKSON'S ROCKY RIDGE PHARMACY, INC

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	333600000X	Pharmacy	111519	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0102018	OTHER	AL	NCPDP

General Provider Information

NPI Number	:	1326043522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON'S ROCKY RIDGE PHARMACY, INC

Provider Business Mailing Address
First Line	:	3346 MORGAN DR
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35216-3052
Country	:	US
Telephone Number	:	205-822-5200
Fax Number	:	205-979-3666

Provider Business Practice Location Address
First Line	:	3346 MORGAN DR
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35216-3052
Country	:	US
Telephone Number	:	205-822-5200
Fax Number	:	205-979-3666

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRAD F JACKSON
Credential	:	PHARM D
Telephone Number	:	205-822-5200

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	05/12/2008

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