1770644866 NPI number — JACKS ENTERPRISES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770644866 NPI number — JACKS ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKS ENTERPRISES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JACK'S DISCOUNT DRUGS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770644866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15073 S US HIGHWAY 231
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND CITY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36350-6305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-983-4191
Provider Business Mailing Address Fax Number:
334-983-5178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15073 S US HIGHWAY 231
Provider Second Line Business Practice Location Address:
MIDTOWN SHOPPING CENTER
Provider Business Practice Location Address City Name:
MIDLAND CITY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36350-6305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-983-4191
Provider Business Practice Location Address Fax Number:
334-983-5178
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
ABBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
334-983-4191

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1993443 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100002671 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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