Provider Demographics
NPI:1215098033
Name:JACKS ENTERPRISES-DOTHAN INC
Entity type:Organization
Organization Name:JACKS ENTERPRISES-DOTHAN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-836-0890
Mailing Address - Street 1:1909 HONEYSUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4289
Mailing Address - Country:US
Mailing Address - Phone:334-836-0890
Mailing Address - Fax:334-836-0894
Practice Address - Street 1:1909 HONEYSUCKLE RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4289
Practice Address - Country:US
Practice Address - Phone:334-836-0890
Practice Address - Fax:334-836-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1126133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0132857OtherNCPDP PROVIDER IDENTIFICATION NUMBER