MEDICARE: JACKS ENTERPRISES 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	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1993443	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770644866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKS ENTERPRISES INC

Provider Business Mailing Address
First Line	:	15073 S US HIGHWAY 231
Second Line	:
City	:	MIDLAND CITY
State	:	AL
Zip	:	36350-6305
Country	:	US
Telephone Number	:	334-983-4191
Fax Number	:	334-983-5178

Provider Business Practice Location Address
First Line	:	15073 S US HIGHWAY 231
Second Line	:	MIDTOWN SHOPPING CENTER
City	:	MIDLAND CITY
State	:	AL
Zip	:	36350-6305
Country	:	US
Telephone Number	:	334-983-4191
Fax Number	:	334-983-5178

Authorized Official
Title or Position	:	PHARMACIST
Name	:	ABBIE DAVIS
Credential	:	PHARMD
Telephone Number	:	334-983-4191

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	10/26/2021

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Directions to “JACKS ENTERPRISES INC ” Practice Location

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