Provider Demographics
NPI:1710069554
Name:JLKGT INVESTMENTS LLC
Entity Type:Organization
Organization Name:JLKGT INVESTMENTS LLC
Other - Org Name:KAUP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-526-3337
Mailing Address - Street 1:42 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:OH
Mailing Address - Zip Code:45380-1214
Mailing Address - Country:US
Mailing Address - Phone:937-526-3337
Mailing Address - Fax:937-526-4118
Practice Address - Street 1:42 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:OH
Practice Address - Zip Code:45380-1214
Practice Address - Country:US
Practice Address - Phone:937-526-3337
Practice Address - Fax:937-526-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
OH0224521003336C0003X
OH0212830503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112030Medicaid
2148087OtherPK
7370700001Medicare NSC