MEDICARE: JOHNNYS HOMETOWN PHARMACY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	343841	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2074722	OTHER	PK

General Provider Information

NPI Number	:	1346223328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNNYS HOMETOWN PHARMACY PC

Provider Business Mailing Address
First Line	:	PO BOX 1600
Second Line	:
City	:	ROLAND
State	:	OK
Zip	:	74954-1600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 E RAY FINE BLVD
Second Line	:	STE 100
City	:	ROLAND
State	:	OK
Zip	:	74954-5362
Country	:	US
Telephone Number	:	918-427-0400
Fax Number	:	918-427-0401

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHNNY ROBERTS
Credential	:
Telephone Number	:	918-427-0400

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	07/10/2014

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