Provider Demographics
NPI:1346322120
Name:MT JACKSON DRUG STORE INC
Entity Type:Organization
Organization Name:MT JACKSON DRUG STORE INC
Other - Org Name:MT JACKSON DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:FANSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-477-3101
Mailing Address - Street 1:PO BOX 473
Mailing Address - Street 2:
Mailing Address - City:MOUNT JACKSON
Mailing Address - State:VA
Mailing Address - Zip Code:22842-0473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5350 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT JACKSON
Practice Address - State:VA
Practice Address - Zip Code:22842-9511
Practice Address - Country:US
Practice Address - Phone:540-477-3101
Practice Address - Fax:540-477-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
VA02010025873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2102235OtherPK
VA010078059Medicaid
VA010078059Medicaid