Provider Demographics
NPI:1326059825
Name:JAC STORES INC
Entity Type:Organization
Organization Name:JAC STORES INC
Other - Org Name:SAV MOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & OWNER
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:217-362-6226
Mailing Address - Street 1:PO BOX 3040
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62524-3040
Mailing Address - Country:US
Mailing Address - Phone:217-362-6226
Mailing Address - Fax:217-362-6241
Practice Address - Street 1:122 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1549
Practice Address - Country:US
Practice Address - Phone:815-692-4343
Practice Address - Fax:815-692-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540081063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1447603OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1447603OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========003Medicaid