Provider Demographics
NPI:1881683795
Name:JACK P HERICK INC
Entity Type:Organization
Organization Name:JACK P HERICK INC
Other - Org Name:GLADES DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:561-924-7701
Mailing Address - Street 1:109 S LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PAHOKEE
Mailing Address - State:FL
Mailing Address - Zip Code:33476-1803
Mailing Address - Country:US
Mailing Address - Phone:561-924-7701
Mailing Address - Fax:561-924-9933
Practice Address - Street 1:109 S LAKE AVE
Practice Address - Street 2:
Practice Address - City:PAHOKEE
Practice Address - State:FL
Practice Address - Zip Code:33476-1803
Practice Address - Country:US
Practice Address - Phone:561-924-7701
Practice Address - Fax:561-924-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH11493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1018591OtherNCPDP
FL015317200Medicaid