Provider Demographics
NPI:1356337117
Name:JESPERSEN FAMILY DRUG INC.
Entity type:Organization
Organization Name:JESPERSEN FAMILY DRUG INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JESPERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:972-298-4936
Mailing Address - Street 1:302 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-3651
Mailing Address - Country:US
Mailing Address - Phone:972-298-4936
Mailing Address - Fax:972-296-9844
Practice Address - Street 1:302 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-3651
Practice Address - Country:US
Practice Address - Phone:972-298-4936
Practice Address - Fax:972-296-9844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11685332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX015622601Medicaid
TX086683201Medicaid
TXPH0477OtherMEDICARE LOCAL PART B PN
TX015622603Medicaid
TX506881OtherBLUE CROSS BLUESHIELD
TX015622603Medicaid