Healthcare Provider Details

I. General information

NPI: 1093753196
Provider Name (Legal Business Name): JELLICO DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 S MAIN ST
JELLICO TN
37762-2018
US

IV. Provider business mailing address

229 S MAIN ST
JELLICO TN
37762-2018
US

V. Phone/Fax

Practice location:
  • Phone: 423-784-6226
  • Fax: 423-784-2947
Mailing address:
  • Phone: 423-784-6226
  • Fax: 423-784-2947

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 TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number472
License Number StateTN

VIII. Authorized Official

Name: MR. JOHN BAIRD
Title or Position: OWNER / PHARMACIST / PRESIDENT
Credential:
Phone: 423-784-6226