=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982746400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JP COMPANIES OF VIRGINIA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 03/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 S 13TH AVE
-----------------------------------------------------
City | VIRGINIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55792-3364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-749-8943
-----------------------------------------------------
Fax | 218-749-8954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 S 13TH AVE PO BOX 76
-----------------------------------------------------
City | VIRGINIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55792-3364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-749-8943
-----------------------------------------------------
Fax | 218-749-8954
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERRY JOHN PROSNICK
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 218-749-8943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 260477-6
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------