Provider Demographics
NPI:1245411297
Name:JAC STORES INC
Entity Type:Organization
Organization Name:JAC STORES INC
Other - Org Name:SAVMOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FALK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-965-4926
Mailing Address - Street 1:105 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:VIRDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62690-1450
Mailing Address - Country:US
Mailing Address - Phone:217-965-4926
Mailing Address - Fax:217-965-5620
Practice Address - Street 1:105 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:VIRDEN
Practice Address - State:IL
Practice Address - Zip Code:62690-1450
Practice Address - Country:US
Practice Address - Phone:217-965-4926
Practice Address - Fax:217-965-5620
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAC STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
0746390003Medicare NSC