Provider Demographics
NPI:1457314916
Name:JACKSONVILLE PHARMACY, INC.
Entity Type:Organization
Organization Name:JACKSONVILLE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:J.
Authorized Official - Middle Name:KEN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-899-7948
Mailing Address - Street 1:725 N 5TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9874
Mailing Address - Country:US
Mailing Address - Phone:541-899-7948
Mailing Address - Fax:541-899-7946
Practice Address - Street 1:725 N 5TH ST
Practice Address - Street 2:STE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9874
Practice Address - Country:US
Practice Address - Phone:541-899-7948
Practice Address - Fax:541-899-7946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275501Medicaid
OR6082810001Medicare NSC