Provider Demographics
NPI:1356455323
Name:JASPER PHARMACY INC
Entity Type:Organization
Organization Name:JASPER PHARMACY INC
Other - Org Name:JASPER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:870-446-5515
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AR
Mailing Address - Zip Code:72641-0520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AR
Practice Address - Zip Code:72641-0520
Practice Address - Country:US
Practice Address - Phone:870-446-5515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR186373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR125725407Medicaid
1995499OtherPK
AR125725407Medicaid