Provider Demographics
NPI:1790289163
Name:JACKISCH DRUG STORE, LLC
Entity Type:Organization
Organization Name:JACKISCH DRUG STORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTROBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-316-2031
Mailing Address - Street 1:115 MILLS ST
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164-6800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:426 PAGOSA STREET
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-4166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy