Jacks Pharmacy Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

1368CP Issued in ID

Legal business name

JACKS PHARMACY INC

Practice address

103 E College Ave
St Maries, ID 83861-2247

Phone

(208) 245-4578

Fax

(208) 245-5004

NPI assigned

Jul 28, 2005

Organization subpart

No

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

Authorized official

Name

Benjamin Ralph Potter

Title

Ceo

Phone

(208) 719-9095

Specialties & licenses 2

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in ID2 enrollments

Enrollment records 2

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Jacks Pharmacy Inc

  • Durable Medical Equipment & Medical Supplies
  • St Maries, ID
  • NPI 1619001187

  O20100930007998

  Same enrollment

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jeffrey Alan Bash, PHARM-D

  • Pharmacist
  • St Maries, ID
  • NPI 1023617883
  NPD (past)
• Di Ann Butterfield, PHARMD

  • Pharmacist
  • St Maries, ID
  • NPI 1396225827
  NPD (past)
• Thomas M Duyck, RPH

  • Pharmacist
  • Plummer, ID
  • NPI 1598431553
  NPD (past)
• Brook Allison Kotlarz, PHARMD

  • Pharmacist
  • St Maries, ID
  • NPI 1124718051
  NPD (past)
• Jeramy Randall Neibaur, PHARMD

  • Pharmacist
  • Rexburg, ID
  • NPI 1194219634
  NPD (past)

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

{
    "created_epoch": "1122508800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1772409600000",
    "number": "1518967710",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 E COLLEGE AVE",
            "city": "ST MARIES",
            "state": "ID",
            "postal_code": "838612247",
            "telephone_number": "208-245-4578",
            "fax_number": "208-245-5004"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 E COLLEGE AVE",
            "city": "ST MARIES",
            "state": "ID",
            "postal_code": "838612247",
            "telephone_number": "208-245-4578",
            "fax_number": "208-245-5004"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKS PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-28",
        "last_updated": "2026-03-02",
        "certification_date": "2026-03-02",
        "status": "A",
        "authorized_official_last_name": "POTTER",
        "authorized_official_first_name": "BENJAMIN",
        "authorized_official_middle_name": "RALPH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "208-719-9095"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "ID",
            "license": "1368CP",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002494400",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002494500",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "1303483",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Anna Louise Humphrey, RDN
• Idaho Dept of Health & Welfare Reg 1 Amh
• Idaho Dept of Health & Welfare Reg 1 Amh PSR St Maries
• Idaho Partners in Care
• Inland Northwest Surgery Center PLLC (Family Foot Center)
• Jacks Pharmacy Inc
• Taylor Elizabeth Johnson, OT
• Jordan Johnston, DPT
• JP Therapy PLLC
• John Richard Katovich Jr., MD

• Community/Retail Pharmacy in St Maries, ID
• Providers in St Maries, ID by specialty
• Community/Retail Pharmacy in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 2, 2026; 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.