Provider Demographics
NPI:1427073790
Name:J & L PHARMACY, INC
Entity type:Organization
Organization Name:J & L PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-822-3575
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:200 W 26TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-3232
Practice Address - Country:US
Practice Address - Phone:979-822-3575
Practice Address - Fax:979-823-7278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12500332B00000X, 332BC3200X, 332BP3500X, 332BX2000X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX013833101Medicaid
TX750655OtherBCBS HIT
TX1209983-04Medicaid
TX519933OtherBCBS DME
104686100OtherFIRSTCARE
722475922-0001OtherCHAMPUS
TX1209983-02Medicaid
=========OtherTRICARE
722475922-0001OtherCHAMPUS