Provider Demographics
NPI:1609969039
Name:JERRYS ENTERPRISES INC
Entity Type:Organization
Organization Name:JERRYS ENTERPRISES INC
Other - Org Name:COUNTY MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:952-928-1698
Mailing Address - Street 1:2310 CREST VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9315
Mailing Address - Country:US
Mailing Address - Phone:715-381-5923
Mailing Address - Fax:715-381-5993
Practice Address - Street 1:2310 CREST VIEW DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9315
Practice Address - Country:US
Practice Address - Phone:715-381-5923
Practice Address - Fax:715-381-5993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8363-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2108748OtherPK
WI33272100Medicaid
2108748OtherPK