Basic Information
| Provider Information | |||||||||
| NPI: | 1780192690 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON ONCOLOGY ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACKSON ONCOLOGY ASSOCIATES, PLLC ORAL DISPENSE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1227 N STATE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013552485 | ||||||||
| FaxNumber: | 6013531463 | ||||||||
| Practice Location | |||||||||
| Address1: | 1227 N STATE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013552485 | ||||||||
| FaxNumber: | 6013531463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2018 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIFFITH | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6019745578 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON ONCOLOGY ASSOCIATES | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | MS | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.