Provider Demographics
NPI:1568257905
Name:JAC STORES INC
Entity type:Organization
Organization Name:JAC STORES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:217-433-6226
Mailing Address - Fax:
Practice Address - Street 1:104 E SOUTHLINE RD
Practice Address - Street 2:
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953-2075
Practice Address - Country:US
Practice Address - Phone:217-253-2309
Practice Address - Fax:217-253-5073
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAC STORES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy