Provider Demographics
NPI:1649619222
Name:CAREDIRECT RX OF JACKSON, LLC
Entity type:Organization
Organization Name:CAREDIRECT RX OF JACKSON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PORTER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOLLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-414-6681
Mailing Address - Street 1:PO BOX 531144
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35253-1144
Mailing Address - Country:US
Mailing Address - Phone:205-414-6681
Mailing Address - Fax:205-930-0405
Practice Address - Street 1:112 CELTIC DR STE 200A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1800
Practice Address - Country:US
Practice Address - Phone:256-325-2148
Practice Address - Fax:256-325-2168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
AL1141233336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140602OtherPK