Provider Demographics
NPI:1710207188
Name:JERKINS INC
Entity Type:Organization
Organization Name:JERKINS INC
Other - Org Name:EAST TALLASSEE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-252-1688
Mailing Address - Street 1:4366 NOTASULGA RD
Mailing Address - Street 2:
Mailing Address - City:TALLASSEE
Mailing Address - State:AL
Mailing Address - Zip Code:36078-6035
Mailing Address - Country:US
Mailing Address - Phone:334-252-1688
Mailing Address - Fax:334-252-1690
Practice Address - Street 1:4366 NOTASULGA RD
Practice Address - Street 2:
Practice Address - City:TALLASSEE
Practice Address - State:AL
Practice Address - Zip Code:36078-6035
Practice Address - Country:US
Practice Address - Phone:334-252-1688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1133733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0136526OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AL172260Medicaid
AL169380Medicaid