Provider Demographics
NPI:1730783630
Name:GRIFFIN, JACKIE L (RPH)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 W 1100 N
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46115-9593
Mailing Address - Country:US
Mailing Address - Phone:317-403-7645
Mailing Address - Fax:
Practice Address - Street 1:263 W MORGAN ST
Practice Address - Street 2:
Practice Address - City:KNIGHTSTOWN
Practice Address - State:IN
Practice Address - Zip Code:46148-9312
Practice Address - Country:US
Practice Address - Phone:765-345-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017257A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist