Provider Demographics
NPI:1114082153
Name:ST JAY PHARMACY INC
Entity Type:Organization
Organization Name:ST JAY PHARMACY INC
Other - Org Name:DBA WELLS RIVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:STRAIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-757-2244
Mailing Address - Street 1:PO BOX 672
Mailing Address - Street 2:
Mailing Address - City:WELLS RIVER
Mailing Address - State:VT
Mailing Address - Zip Code:05081-0672
Mailing Address - Country:US
Mailing Address - Phone:802-757-2244
Mailing Address - Fax:
Practice Address - Street 1:41 MAIN ST N.
Practice Address - Street 2:
Practice Address - City:WELLS RIVER
Practice Address - State:VT
Practice Address - Zip Code:05081-0672
Practice Address - Country:US
Practice Address - Phone:802-757-2244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT03800033293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008262Medicaid
NH30701654Medicaid
VT1008262Medicaid