Provider Demographics
NPI:1881948305
Name:JAC STORES INC
Entity type:Organization
Organization Name:JAC STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/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:217-362-6226
Mailing Address - Fax:217-362-6241
Practice Address - Street 1:59 CEDAR SQ
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-2201
Practice Address - Country:US
Practice Address - Phone:217-935-0315
Practice Address - Fax:217-935-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL0540180543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487443OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1487443OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1487443OtherNCPDP PROVIDER IDENTIFICATION NUMBER