MEDICARE: JAC STORES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	054005154	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2016687	OTHER		PK

General Provider Information

NPI Number	:	1093726598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAC STORES INC

Provider Business Mailing Address
First Line	:	2245 W MOUND RD
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62526-9367
Country	:	US
Telephone Number	:	217-362-6226
Fax Number	:	217-362-6241

Provider Business Practice Location Address
First Line	:	104 E SOUTHLINE RD
Second Line	:	ROUTE 36 UNIT A
City	:	TUSCOLA
State	:	IL
Zip	:	61953-2075
Country	:	US
Telephone Number	:	217-253-2309
Fax Number	:	217-253-5073

Authorized Official
Title or Position	:	PRESIDENT & OWNER
Name	:	DAVID FALK
Credential	:
Telephone Number	:	217-362-6226

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	10/17/2024

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Directions to “JAC STORES INC ” Practice Location

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