Provider Demographics
NPI:1255314258
Name:JEBS INC
Entity Type:Organization
Organization Name:JEBS INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:NUCKOLS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:540-772-0605
Mailing Address - Street 1:4375 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3404
Mailing Address - Country:US
Mailing Address - Phone:540-772-0605
Mailing Address - Fax:540-772-0601
Practice Address - Street 1:4375 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3404
Practice Address - Country:US
Practice Address - Phone:540-772-0605
Practice Address - Fax:540-772-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010033503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4829909OtherNCPDP #
VA8508399Medicaid
VA8508399Medicaid
VA1151830001Medicare NSC
VA8508399Medicaid
VA870023535Medicare PIN