Provider Demographics
NPI:1295830578
Name:JR PHARMACY ROCKVILLE LLC 4
Entity Type:Organization
Organization Name:JR PHARMACY ROCKVILLE LLC 4
Other - Org Name:JR PHARMACY ROCKVILLE LLC 4 & JR PHARMACY ROCKVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VENCEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-234-8305
Mailing Address - Street 1:1238 S 3RD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-1006
Mailing Address - Country:US
Mailing Address - Phone:812-234-8305
Mailing Address - Fax:812-234-0225
Practice Address - Street 1:1330 N LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872-1215
Practice Address - Country:US
Practice Address - Phone:765-569-6900
Practice Address - Fax:765-569-5797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
IN60005901A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2025250OtherPK
IN200522310Medicaid
IN200522310Medicaid