Active NPI
Nicholas Dwayne Jackson, PHARMD
- Pharmacist
- Coeburn, VA
National Provider Identifier
1528670916
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 0202208432
- Practice address
- 201 Laurel Ave
Coeburn, VA 24293 - Phone
- (276) 807-7106
- Fax
- (276) 807-7341
- NPI assigned
- Aug 18, 2020
- Last updated
- Aug 18, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 0202208432 | VA | Primary |
Addresses
Primary practice location
201 Laurel Ave
Coeburn, VA 24293
Mailing address
PO Box 1439
Coeburn, VA 24230-1439
Phone (276) 807-7106
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Pharmacy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0202208432 | VA | MD | Pharmacist |
Practice roles
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1597708800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1597708800000",
"number": "1528670916",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1439",
"city": "COEBURN",
"state": "VA",
"postal_code": "242301439",
"telephone_number": "276-807-7106",
"fax_number": "276-807-7341"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "201 LAUREL AVE",
"city": "COEBURN",
"state": "VA",
"postal_code": "24293",
"telephone_number": "276-807-7106",
"fax_number": "276-807-7341"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "NICHOLAS",
"middle_name": "DWAYNE",
"credential": "PHARMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-08-18",
"last_updated": "2020-08-18",
"certification_date": "2020-08-18",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "VA",
"license": "0202208432",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Coeburn, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.