Healthcare Provider Details

I. General information

NPI: 1871136986
Provider Name (Legal Business Name): JAY'S ROADHOUSE AND PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 LINCOLN AVE
STEAMBOAT SPRINGS CO
80487-5005
US

IV. Provider business mailing address

42225 DEER RD
STEAMBOAT SPRINGS CO
80487-9159
US

V. Phone/Fax

Practice location:
  • Phone: 970-879-1114
  • Fax: 970-879-5643
Mailing address:
  • Phone: 970-871-4596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW TODD JOHNSON
Title or Position: PHARMACIST/OWNER
Credential: PHARM.D.
Phone: 970-291-8813