MEDICARE: JAC PHARMACY INC

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	3336C0003X	Community/Retail Pharmacy	018088	NY
2	333600000X	Pharmacy	018088	NY

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
2	3379511	OTHER		NCPDP

General Provider Information

NPI Number	:	1679518781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAC PHARMACY INC

Provider Business Mailing Address
First Line	:	9315 ROOSEVELT AVE
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-7943
Country	:	US
Telephone Number	:	718-478-7968
Fax Number	:	718-478-7969

Provider Business Practice Location Address
First Line	:	9315 ROOSEVELT AVE
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-7943
Country	:	US
Telephone Number	:	718-478-6863
Fax Number	:	718-478-0093

Authorized Official
Title or Position	:	LEGAL
Name	:	MR. JOSE CAMPON
Credential	:	JD
Telephone Number	:	516-523-6948

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	08/13/2017

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Directions to “JAC PHARMACY INC ” Practice Location

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