Healthcare Provider Details

I. General information

NPI: 1831633445
Provider Name (Legal Business Name): JOLLYS DRUG STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N SPRING ST
CALIENTE NV
89008-0100
US

IV. Provider business mailing address

PO BOX 1011
CALIENTE NV
89008-1011
US

V. Phone/Fax

Practice location:
  • Phone: 775-726-3771
  • Fax: 775-726-3685
Mailing address:
  • Phone: 775-726-3771
  • Fax: 775-726-3685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH03644
License Number StateNV

VIII. Authorized Official

Name: JONATHAN HEATON
Title or Position: OWNER
Credential:
Phone: 775-726-3771