Provider Demographics
NPI:1609426022
Name:JACKSON, GARY DEAN (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:DEAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11340 THREE RIVERS RD STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3650
Mailing Address - Country:US
Mailing Address - Phone:228-832-8000
Mailing Address - Fax:228-832-0808
Practice Address - Street 1:11340 THREE RIVERS RD STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3650
Practice Address - Country:US
Practice Address - Phone:228-832-8000
Practice Address - Fax:228-832-0808
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-06793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist