Healthcare Provider Details

I. General information

NPI: 1144358466
Provider Name (Legal Business Name): JKBC WOLF INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 03/07/2023
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W MADISON AVE
ATHENS TN
37303-3433
US

IV. Provider business mailing address

PO BOX 1187
ATHENS TN
37371-1187
US

V. Phone/Fax

Practice location:
  • Phone: 423-746-2626
  • Fax: 423-746-2624
Mailing address:
  • Phone: 423-746-2626
  • Fax: 423-746-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3583
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1452528
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 2
Identifier4434584
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerNCPDP

VIII. Authorized Official

Name: JEFFRY H WOLFENDEN
Title or Position: PRESIDENT
Credential: RPH
Phone: 423-746-2626