Provider Demographics
NPI:1619001187
Name:JACKS PHARMACY INC
Entity Type:Organization
Organization Name:JACKS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COLT
Authorized Official - Middle Name:
Authorized Official - Last Name:DARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-245-4578
Mailing Address - Street 1:103 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-2247
Mailing Address - Country:US
Mailing Address - Phone:208-245-4578
Mailing Address - Fax:208-245-5004
Practice Address - Street 1:103 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2247
Practice Address - Country:US
Practice Address - Phone:208-245-4578
Practice Address - Fax:208-245-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1368CP332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1303483OtherNCPDP
ID002494500Medicaid
ID002494400Medicaid