Provider Demographics
NPI:1902803141
Name:J & B DRUG STORE, INC.
Entity type:Organization
Organization Name:J & B DRUG STORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER AND CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JARVIS-STOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-354-7737
Mailing Address - Street 1:PO BOX 560
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26147-0560
Mailing Address - Country:US
Mailing Address - Phone:304-354-7737
Mailing Address - Fax:304-354-7807
Practice Address - Street 1:352 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26147
Practice Address - Country:US
Practice Address - Phone:304-354-7737
Practice Address - Fax:304-354-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WVSP05501363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2109383OtherPK
WV0142545000Medicaid
0171470001Medicare NSC