MEDICARE: MR. JOHN MICHAEL JACKSON R.PH.

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	03215600	OH

General Provider Information

NPI Number	:	1679830558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN MICHAEL JACKSON R.PH.

Provider Business Mailing Address
First Line	:	1000 CASTLEBAY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-4910
Country	:	US
Telephone Number	:	513-739-3784
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 CASTLEBAY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-4910
Country	:	US
Telephone Number	:	513-739-3784
Fax Number	:

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

Provider Enumeration Date	:	04/18/2012
Last Update Date	:	07/27/2016

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