Provider Demographics
NPI:1477541019
Name:JAFFE DRUG STORES INC
Entity Type:Organization
Organization Name:JAFFE DRUG STORES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-933-3369
Mailing Address - Street 1:217 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3824
Mailing Address - Country:US
Mailing Address - Phone:815-933-3369
Mailing Address - Fax:815-933-3380
Practice Address - Street 1:217 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3824
Practice Address - Country:US
Practice Address - Phone:815-933-3369
Practice Address - Fax:815-933-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054001269333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1406138OtherNABP #
IL0512760001Medicare NSC