| Entity Name: | JACK P. HERICK, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 19 Nov 1965 (59 years ago) |
| Document Number: | 298855 |
| FEI/EIN Number | 591107025 |
| Mail Address: | 6119 Lyons Road, Coconut Creek, FL, 33073-4740, US |
| Address: | 109 SOUTH LAKE AVE, PAHOKEE, FL, 33476, US |
| ZIP code: | 33476 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1881683795 | 2005-10-14 | 2015-10-19 | 109 S LAKE AVE, PAHOKEE, FL, 334761803, US | 109 S LAKE AVE, PAHOKEE, FL, 334761803, US | |||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||
| Phone | +1 561-924-7701 |
| Fax | 5619249933 |
Authorized person
| Name | TERRENCE MYERS |
| Role | PRESIDENT |
| Phone | 5619247701 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH1149 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | NCPDP |
| Number | 1018591 |
| State | FL |
| Issuer | MEDICAID |
| Number | 015317200 |
| State | FL |
| Name | Role |
|---|---|
| NRAI SERVICES, INC. | Agent |
| Name | Role | Address |
|---|---|---|
| Lansman Daniel L | Treasurer | 6119 Lyons Road, Coconut Creek, FL, 330734740 |
| Name | Role | Address |
|---|---|---|
| Myers Terry | President | 120 North Federal Highway, Lake Worth, FL, 33460 |
| Name | Role | Address |
|---|---|---|
| Goodkin Ryan | Secretary | 120 North Federal Highway, Boca Raton, FL, 33460 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G14000092823 | GLADES DRUGS | EXPIRED | 2014-09-11 | 2019-12-31 | No data | 1095 BROKEN SOUND PARKWAY NORTH WEST, SUITE #300, BOCA RATON, FL, 33487 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISS W/ NOTICE | 2019-05-13 | No data | No data |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
