Provider Demographics
NPI:1871658922
Name:JACKISCH DRUG, INC.
Entity Type:Organization
Organization Name:JACKISCH DRUG, INC.
Other - Org Name:HEALTHY DRUGSTORE, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOCITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-264-4166
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-0120
Mailing Address - Country:US
Mailing Address - Phone:970-264-4166
Mailing Address - Fax:970-355-6448
Practice Address - Street 1:426 PAGOSA ST.
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-0000
Practice Address - Country:US
Practice Address - Phone:970-264-4166
Practice Address - Fax:970-264-3289
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHY DRUGSTORE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO100000013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03433000Medicaid
CO0605470OtherNAPB,NCPDP
CO0605470OtherNAPB,NCPDP
COBJ9020277OtherDEA