Provider Demographics
NPI:1093827909
Name:CITY DRUG STORE OF JACKSBORO, INC
Entity Type:Organization
Organization Name:CITY DRUG STORE OF JACKSBORO, INC
Other - Org Name:CITY DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:VANVACTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:940-567-5576
Mailing Address - Street 1:104 E BELKNAP ST
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76458-2401
Mailing Address - Country:US
Mailing Address - Phone:940-567-5576
Mailing Address - Fax:940-567-3815
Practice Address - Street 1:104 E BELKNAP ST
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458-2401
Practice Address - Country:US
Practice Address - Phone:940-567-5576
Practice Address - Fax:940-567-3815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX1393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120408Medicaid
2097943OtherPK