Provider Demographics
NPI:1033399977
Name:JBS, INC
Entity Type:Organization
Organization Name:JBS, INC
Other - Org Name:WALTHER PHARMACY & SURGICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SURAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMMEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-344-7799
Mailing Address - Street 1:8621 WALTHER BLVD
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3039
Mailing Address - Country:US
Mailing Address - Phone:410-344-7799
Mailing Address - Fax:410-878-7807
Practice Address - Street 1:8621 WALTHER BLVD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-3039
Practice Address - Country:US
Practice Address - Phone:410-344-7799
Practice Address - Fax:410-878-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP04678302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6072120001Medicare NSC