Organization
JACKS PHARMACY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BENJAMIN RALPH POTTER (CEO)
(208) 719-9095
Entity
Organization
Contact information
Practice address
103 E COLLEGE AVE, ST MARIES, ID 83861-2247
(208) 245-4578
(208) 245-5004
Mailing address
103 E COLLEGE AVE, ST MARIES, ID 83861-2247
(208) 245-4578
(208) 245-5004
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1368CP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002494400
—
ID
05
—
002494500
—
ID
01
—
1303483
NCPDP
ID
Enumeration date
07/28/2005
Last updated
03/02/2026
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