Provider Demographics
NPI:1710945381
Name:JAY-KISHUN ENTERPRISE INC
Entity Type:Organization
Organization Name:JAY-KISHUN ENTERPRISE INC
Other - Org Name:RIDGMAR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:KAMLESHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KURANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-737-7377
Mailing Address - Street 1:2524 MALL CIR
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-1545
Mailing Address - Country:US
Mailing Address - Phone:817-737-7377
Mailing Address - Fax:817-737-7388
Practice Address - Street 1:2524 MALL CIR
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-1545
Practice Address - Country:US
Practice Address - Phone:817-737-7377
Practice Address - Fax:817-737-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220473336C0003X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145216Medicaid
2097941OtherPK