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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	054018054	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1487443	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1881948305
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	:	59 CEDAR SQ
Second Line	:
City	:	CLINTON
State	:	IL
Zip	:	61727-2201
Country	:	US
Telephone Number	:	217-935-0315
Fax Number	:	217-935-0319

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

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	02/22/2013

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Directions to “JAC STORES INC ” Practice Location

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