Provider Demographics
NPI:1093753196
Name:JELLICO DRUG STORE INC
Entity Type:Organization
Organization Name:JELLICO DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHARMACIST / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-784-6226
Mailing Address - Street 1:229 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2018
Mailing Address - Country:US
Mailing Address - Phone:423-784-6226
Mailing Address - Fax:423-784-2947
Practice Address - Street 1:229 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2018
Practice Address - Country:US
Practice Address - Phone:423-784-6226
Practice Address - Fax:423-784-2947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X
TN4723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4407210Medicaid
0910560001Medicare NSC