Healthcare Provider Details

I. General information

NPI: 1477541019
Provider Name (Legal Business Name): JAFFE DRUG STORES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E COURT ST
KANKAKEE IL
60901-3824
US

IV. Provider business mailing address

217 E COURT ST
KANKAKEE IL
60901-3824
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-3369
  • Fax: 815-933-3380
Mailing address:
  • Phone: 815-933-3369
  • Fax: 815-933-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054001269
License Number StateIL

VIII. Authorized Official

Name: MR. FREDERICK JAFFE
Title or Position: PHARMACIST IN CHARGE
Credential: R.PH.
Phone: 815-933-3369