=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942365002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JB PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 W NORTHERN AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-545-1811
-----------------------------------------------------
Fax | 719-545-3878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 W NORTHERN AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-545-1811
-----------------------------------------------------
Fax | 719-545-3878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER-OWNER
-----------------------------------------------------
Name | JEANETTE MARIE BURNS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-545-1811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 1040000035
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PDO1040000035
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PDO1040000035
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------