Provider Demographics
NPI:1366453862
Name:JAC STORES INC
Entity type:Organization
Organization Name:JAC STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FALK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-362-6226
Mailing Address - Street 1:2245 W MOUND RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 E STATE ST
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:IL
Practice Address - Zip Code:62075-1340
Practice Address - Country:US
Practice Address - Phone:217-563-8346
Practice Address - Fax:217-563-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540061643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017269OtherPK
2017269OtherPK
0746390001Medicare NSC