Healthcare Provider Details

I. General information

NPI: 1346223328
Provider Name (Legal Business Name): JOHNNYS HOMETOWN PHARMACY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E RAY FINE BLVD STE 100
ROLAND OK
74954-5362
US

IV. Provider business mailing address

PO BOX 1600
ROLAND OK
74954-1600
US

V. Phone/Fax

Practice location:
  • Phone: 918-427-0400
  • Fax: 918-427-0401
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number343841
License Number StateOK

VIII. Authorized Official

Name: JOHNNY ROBERTS
Title or Position: PRESIDENT
Credential:
Phone: 918-427-0400