MEDICARE: LONNIE EVERRETT JACKSON III P.D.

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	PD06643	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0413396	OTHER		NABP#

General Provider Information

NPI Number	:	1477637841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LONNIE EVERRETT JACKSON III P.D.

Provider Business Mailing Address
First Line	:	1305 WHITE DR
Second Line	:	P.O. BOX 2114
City	:	BATESVILLE
State	:	AR
Zip	:	72501-9467
Country	:	US
Telephone Number	:	870-698-1974
Fax Number	:	870-698-0141

Provider Business Practice Location Address
First Line	:	1305 WHITE DR
Second Line	:
City	:	BATESVILLE
State	:	AR
Zip	:	72501-9467
Country	:	US
Telephone Number	:	870-698-1974
Fax Number	:	870-698-0141

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/09/2007

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