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General NPI Number Information
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NPI Number | 1619001187
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Entity Type | Organization
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Legal Business Name | JACKS PHARMACY INC
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 04/23/2025
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Provider Practice Location Address
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Address Line | 103 E COLLEGE AVE
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City | ST MARIES
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State | ID
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Zip | 83861-2247
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Country | US
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Telephone | 208-245-4578
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Fax | 208-245-5004
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Provider Business Mailing Address
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Address Line | 103 E COLLEGE AVE
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City | ST MARIES
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State | ID
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Zip | 83861-2247
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Country | US
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Telephone | 208-245-4578
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Fax | 208-245-5004
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Authorized Official
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Title or Position | PHARMACIST/PRESIDENT
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Name | DR. COLT DARLEY
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Credential | PHARMD
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Telephone | 208-245-4578
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 1368CP
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License Number State | ID
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