Provider Demographics
NPI:1053410811
Name:JAB CLINIC PHARMACY INC
Entity type:Organization
Organization Name:JAB CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-251-6385
Mailing Address - Street 1:604 BELUE LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3870
Mailing Address - Country:US
Mailing Address - Phone:318-251-6385
Mailing Address - Fax:318-255-7530
Practice Address - Street 1:604 BELUE LN
Practice Address - Street 2:SUITE A
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3870
Practice Address - Country:US
Practice Address - Phone:318-251-6385
Practice Address - Fax:318-255-7530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
LAPHY.003899-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1264784Medicaid
2032265OtherPK
2032265OtherPK