MEDICARE: JACKSON 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
2	3336C0003X	Community/Retail Pharmacy	AR13396	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1994353	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770570491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 2114
Second Line	:
City	:	BATESVILLE
State	:	AR
Zip	:	72503-2114
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	:	PRESIDENT
Name	:	LONNIE JACKSON
Credential	:	PD
Telephone Number	:	870-698-1974

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	12/05/2016

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Directions to “JACKSON PHARMACY INC ” Practice Location

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