Provider Demographics
NPI:1497766604
Name:JEN&JOSH INC
Entity Type:Organization
Organization Name:JEN&JOSH INC
Other - Org Name:DIERKS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-285-3309
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:DIERKS
Mailing Address - State:AR
Mailing Address - Zip Code:71833-0069
Mailing Address - Country:US
Mailing Address - Phone:870-286-3131
Mailing Address - Fax:870-286-2547
Practice Address - Street 1:323 MAIN ST
Practice Address - Street 2:
Practice Address - City:DIERKS
Practice Address - State:AR
Practice Address - Zip Code:71833-0140
Practice Address - Country:US
Practice Address - Phone:870-286-3131
Practice Address - Fax:870-286-2547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
ARAR163303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR208506407Medicaid
2151012OtherPK