City Drug Store of Jacksboro, Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

139 Issued in TX

Legal business name

CITY DRUG STORE OF JACKSBORO, INC

Doing business as

City Drug Store

Practice address

104 E Belknap St
Jacksboro, TX 76458-2401

Phone

(940) 567-5576

Fax

(940) 567-3815

NPI assigned

Aug 31, 2006

Last updated

Feb 19, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Chandra Renee Vanvacter, PHARMDNPI 1134233240

Title

Owner

Phone

(940) 567-5576

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• CITY DRUG STORE Doing business as

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Chandra Renee Vanvacter, RPH

  • Pharmacist
  • Bridgeport, TX
  • NPI 1134233240
  NPD Authorized official
• James Rodney Hammond, R.PH.

  • Pharmacist
  • Jacksboro, TX
  • NPI 1871621318
  NPD
• Kalyn Qualls, PHARM.D.

  • Pharmacist
  • Jacksboro, TX
  • NPI 1013503986
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708300800000",
    "number": "1093827909",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 E BELKNAP ST",
            "city": "JACKSBORO",
            "state": "TX",
            "postal_code": "764582401",
            "telephone_number": "940-567-5576",
            "fax_number": "940-567-3815"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 E BELKNAP ST",
            "city": "JACKSBORO",
            "state": "TX",
            "postal_code": "764582401",
            "telephone_number": "940-567-5576",
            "fax_number": "940-567-3815"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CITY DRUG STORE OF JACKSBORO, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-31",
        "last_updated": "2024-02-19",
        "certification_date": "2024-02-19",
        "status": "A",
        "authorized_official_last_name": "VANVACTER",
        "authorized_official_first_name": "CHANDRA",
        "authorized_official_middle_name": "RENEE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "940-567-5576",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TX",
            "license": "139",
            "primary": true
        },
        {
            "code": "3336C0004X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Compounding Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "120408",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2097943",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CITY DRUG STORE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jennifer Archer, DO
• Hayden J. Behling, PA-C
• Beyondfaith Homecare & Rehab of Jacksboro, LLC (BeyondFaith Homecare & Hospice of Jacksboro, LLC)
• Ashley Mae Chitwood
• Jessica Coker, APRN, FNP
• Concerned Citizens of Jack Co., Inc.
• Eileen Elizabeth Corson, PTA
• Beverley Ann Crow, LVN
• Courtney Lanette Curtner, RN

• Community/Retail Pharmacy in Jacksboro, TX
• Providers in Jacksboro, TX by specialty
• Community/Retail Pharmacy in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.