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General NPI Number Information
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NPI Number | 1184162844
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Entity Type | Organization
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Legal Business Name | JOLLY'S DRUG STORE LLC
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Dates
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Enumeration Date | 02/02/2017
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Last Update Date | 02/02/2017
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Provider Practice Location Address
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Address Line | 414 BROADWAY
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City | ALAMO
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State | NV
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Zip | 89001
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Country | US
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Telephone | 775-725-3515
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Fax | 775-725-3518
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Provider Business Mailing Address
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Address Line | PO BOX 1011
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City | CALIENTE
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State | NV
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Zip | 89008-1011
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Country | US
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Telephone | 775-725-3515
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Fax | 775-725-3518
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Authorized Official
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Title or Position | OWNER
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Name | JONATHAN HEATON
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Credential |
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Telephone | 801-358-9608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | PH03674
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License Number State | NV
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