Healthcare Provider Details

I. General information

NPI: 1679518781
Provider Name (Legal Business Name): JAC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9315 ROOSEVELT AVE
JACKSON HEIGHTS NY
11372-7943
US

IV. Provider business mailing address

9315 ROOSEVELT AVE
JACKSON HEIGHTS NY
11372-7943
US

V. Phone/Fax

Practice location:
  • Phone: 718-478-6863
  • Fax: 718-478-0093
Mailing address:
  • Phone: 718-478-7968
  • Fax: 718-478-7969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number018088
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number018088
License Number StateNY

VIII. Authorized Official

Name: MR. JOSE CAMPON
Title or Position: LEGAL
Credential: JD
Phone: 516-523-6948