Provider Demographics
NPI:1639254113
Name:PRESCRIPTION CENTER PHARMACY INC.
Entity Type:Organization
Organization Name:PRESCRIPTION CENTER PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-234-9912
Mailing Address - Street 1:2701 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3602
Mailing Address - Country:US
Mailing Address - Phone:701-234-3630
Mailing Address - Fax:701-234-3631
Practice Address - Street 1:2701 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3602
Practice Address - Country:US
Practice Address - Phone:701-234-3630
Practice Address - Fax:701-234-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND023336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20829Medicaid
ND0461370002Medicare NSC