Provider Demographics
NPI:1093707903
Name:ACJK INC
Entity Type:Organization
Organization Name:ACJK INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:PELATE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-451-8001
Mailing Address - Street 1:2770 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3607
Mailing Address - Country:US
Mailing Address - Phone:618-451-8001
Mailing Address - Fax:618-451-8015
Practice Address - Street 1:2770 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3607
Practice Address - Country:US
Practice Address - Phone:618-451-8001
Practice Address - Fax:618-451-8015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54014022332B00000X, 333600000X
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1469736OtherNABP
1469736OtherNABP
1469736OtherNABP
IL1267830001Medicare NSC
IL538320Medicare PIN
ILP00195444Medicare PIN