Provider Demographics
NPI:1679518781
Name:JAC PHARMACY INC
Entity Type:Organization
Organization Name:JAC PHARMACY INC
Other - Org Name:FARMACIA LATINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEGAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPON
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:516-523-6948
Mailing Address - Street 1:9315 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7943
Mailing Address - Country:US
Mailing Address - Phone:718-478-7968
Mailing Address - Fax:718-478-7969
Practice Address - Street 1:9315 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7943
Practice Address - Country:US
Practice Address - Phone:718-478-6863
Practice Address - Fax:718-478-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2017-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018088333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00824075Medicaid
3379511OtherNCPDP
3379511OtherNCPDP