Provider Demographics
NPI:1700398849
Name:JASPER DRUG CO INC
Entity Type:Organization
Organization Name:JASPER DRUG CO INC
Other - Org Name:JASPER DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:706-692-6427
Mailing Address - Street 1:1 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1500
Practice Address - Country:US
Practice Address - Phone:706-692-6427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JASPER DRUG STORE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0061553336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00029873Medicaid