MEDICARE: JACKSONS DRUGS OF MONTICELLO, 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	3336C0003X	Community/Retail Pharmacy	PH12505	FL

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

General Provider Information

NPI Number	:	1528108677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONS DRUGS OF MONTICELLO, INC.

Provider Business Mailing Address
First Line	:	PO BOX 129
Second Line	:
City	:	GREENVILLE
State	:	FL
Zip	:	32331-0129
Country	:	US
Telephone Number	:	850-948-3011
Fax Number	:	850-948-3778

Provider Business Practice Location Address
First Line	:	1308 SW GRAND ST
Second Line	:
City	:	GREENVILLE
State	:	FL
Zip	:	32331
Country	:	US
Telephone Number	:	850-948-3011
Fax Number	:	850-948-3778

Authorized Official
Title or Position	:	VP
Name	:	MR. CHARLES D JACKSON
Credential	:	R.PH.
Telephone Number	:	850-948-3011

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	03/25/2009

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