Provider Demographics
NPI:1902934243
Name:JLSCO LLC
Entity Type:Organization
Organization Name:JLSCO LLC
Other - Org Name:LEE'S MARKETPLACE - NORTH OGDEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:BADGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-774-4150
Mailing Address - Street 1:505 E 1400 N STE 110
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2459
Mailing Address - Country:US
Mailing Address - Phone:435-774-4150
Mailing Address - Fax:435-774-4166
Practice Address - Street 1:2645 N WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414
Practice Address - Country:US
Practice Address - Phone:801-782-6116
Practice Address - Fax:801-782-7222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT6909518-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100308OtherPK
UT=========001Medicaid