Provider Demographics
NPI:1275859571
Name:JAYMARC INC
Entity Type:Organization
Organization Name:JAYMARC INC
Other - Org Name:ROBERTS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-257-3388
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-0728
Mailing Address - Country:US
Mailing Address - Phone:405-257-3388
Mailing Address - Fax:405-257-6508
Practice Address - Street 1:309 S WEWOKA AVE
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-2641
Practice Address - Country:US
Practice Address - Phone:405-257-3388
Practice Address - Fax:405-257-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK24-54893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124569OtherPK
OK200296660AMedicaid