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	332B00000X	Durable Medical Equipment & Medical Supplies	PENDING NPI APPROVAL	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	515-40811	OTHER	AL	BLUE CROSS BLUE SHIELD OF ALABAMA
2	0102018	OTHER	AL	NCPDP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881927192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON'S ROCKY RIDGE PHARMACY, INC

Provider Business Mailing Address
First Line	:	2108 GATEWAY DR
Second Line	:	SUITE F
City	:	OPELIKA
State	:	AL
Zip	:	36801-6886
Country	:	US
Telephone Number	:
Fax Number	:

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	:	09/18/2009
Last Update Date	:	03/07/2023

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