MEDICARE: JACKSONVILLE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	RP002114CS	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407022700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE PHARMACY LLC

Provider Business Mailing Address
First Line	:	725 N 5TH ST STE 100
Second Line	:
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9874
Country	:	US
Telephone Number	:	541-899-7948
Fax Number	:	541-899-7946

Provider Business Practice Location Address
First Line	:	725 N 5TH ST STE 100
Second Line	:
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9874
Country	:	US
Telephone Number	:	541-899-7948
Fax Number	:	541-899-7946

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES KEN JOHNSON
Credential	:	RPH
Telephone Number	:	541-899-7948

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	05/06/2008

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Directions to “JACKSONVILLE PHARMACY LLC ” Practice Location

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