Provider Demographics
NPI:1689729717
Name:JACKSON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:JACKSON COUNTY HOSPITAL DISTRICT
Other - Org Name:JACKSON COUNTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:RIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:361-782-7822
Mailing Address - Street 1:1013 S WELLS ST
Mailing Address - Street 2:BLDG B
Mailing Address - City:EDNA
Mailing Address - State:TX
Mailing Address - Zip Code:77957-4045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1013 S WELLS ST
Practice Address - Street 2:BLDG B
Practice Address - City:EDNA
Practice Address - State:TX
Practice Address - Zip Code:77957-4045
Practice Address - Country:US
Practice Address - Phone:361-782-7822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250423336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4541113OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX145673Medicaid