Provider Demographics
NPI:1316307994
Name:JAC STORES INC
Entity type:Organization
Organization Name:JAC STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AO
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:217-362-6226
Mailing Address - Fax:217-362-6241
Practice Address - Street 1:326 ROUTE 45 N
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:IL
Practice Address - Zip Code:62858-2652
Practice Address - Country:US
Practice Address - Phone:618-665-4828
Practice Address - Fax:618-665-4814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-25
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540196753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157611OtherPK