Provider Demographics
NPI:1114039039
Name:JACK A BESANT INC
Entity Type:Organization
Organization Name:JACK A BESANT INC
Other - Org Name:FOX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BESANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-462-8261
Mailing Address - Street 1:130 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELROY
Mailing Address - State:WI
Mailing Address - Zip Code:53929-1250
Mailing Address - Country:US
Mailing Address - Phone:608-462-8261
Mailing Address - Fax:608-462-8262
Practice Address - Street 1:130 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELROY
Practice Address - State:WI
Practice Address - Zip Code:53929-1250
Practice Address - Country:US
Practice Address - Phone:608-462-8261
Practice Address - Fax:608-462-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI5937-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5113206OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33004800Medicaid
WI33004800Medicaid