Healthcare Provider Details

I. General information

NPI: 1518967710
Provider Name (Legal Business Name): JACKS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E COLLEGE AVE
ST MARIES ID
83861-2247
US

IV. Provider business mailing address

103 E COLLEGE AVE
ST MARIES ID
83861-2247
US

V. Phone/Fax

Practice location:
  • Phone: 208-245-4578
  • Fax: 208-245-5004
Mailing address:
  • Phone: 208-245-4578
  • Fax: 208-245-5004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1368CP
License Number StateID

VIII. Authorized Official

Name: BENJAMIN RALPH POTTER
Title or Position: CEO
Credential:
Phone: 208-719-9095