Provider Demographics
NPI:1922009323
Name:J. PEN MEDICAL, INC.
Entity Type:Organization
Organization Name:J. PEN MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TRES
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:NYGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-652-1989
Mailing Address - Street 1:PO BOX 975
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-0975
Mailing Address - Country:US
Mailing Address - Phone:828-652-1989
Mailing Address - Fax:828-652-8990
Practice Address - Street 1:135 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-4548
Practice Address - Country:US
Practice Address - Phone:828-652-1989
Practice Address - Fax:828-652-8990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00484332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703089Medicaid
C08500402OtherCMS - MEDICARE EDI OPERATIONS - PALMETTO GBA
C08500402OtherCMS - MEDICARE EDI OPERATIONS - PALMETTO GBA