Provider Demographics
NPI:1639124845
Name:KJAA INC
Entity Type:Organization
Organization Name:KJAA INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:STALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-236-3663
Mailing Address - Street 1:320 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1845
Mailing Address - Country:US
Mailing Address - Phone:641-236-3663
Mailing Address - Fax:641-236-0260
Practice Address - Street 1:320 6TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1845
Practice Address - Country:US
Practice Address - Phone:641-236-3663
Practice Address - Fax:641-236-0260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0423228Medicaid
IA1621778OtherNCPDP #
IABM6636091OtherDEA #
IA5042500001Medicare NSC
IAI11199Medicare PIN