Provider Demographics
NPI:1477955037
Name:JACKSON VILLAGE PHARMACY LLC
Entity type:Organization
Organization Name:JACKSON VILLAGE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:860-367-3387
Mailing Address - Street 1:27 S COOKS BRIDGE RD STE M1
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2443
Mailing Address - Country:US
Mailing Address - Phone:732-994-7387
Mailing Address - Fax:732-994-7389
Practice Address - Street 1:27 SOUTH COOKS BRIDGE RD
Practice Address - Street 2:SUITE M1
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527
Practice Address - Country:US
Practice Address - Phone:732-994-7387
Practice Address - Fax:732-994-7389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0002X, 3336L0003X, 3336S0011X
NJ3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7544670001Medicare NSC