Provider Demographics
NPI:1336235902
Name:JAYHAWK HOLDINGS INC
Entity Type:Organization
Organization Name:JAYHAWK HOLDINGS INC
Other - Org Name:MILLY'S PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:612-227-7811
Mailing Address - Street 1:2626 FEDERAL ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08105-1936
Mailing Address - Country:US
Mailing Address - Phone:856-963-0300
Mailing Address - Fax:856-963-2202
Practice Address - Street 1:2626 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08105-1936
Practice Address - Country:US
Practice Address - Phone:856-963-0300
Practice Address - Fax:856-963-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006930003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3135034OtherNCPDP #
NJ0242764Medicaid
NJ0242781OtherMEDICAID DME
3135034OtherNCPDP #