Provider Demographics
NPI:1386653921
Name:JTW PHARMACY INC
Entity Type:Organization
Organization Name:JTW PHARMACY INC
Other - Org Name:WONDER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:TILLEY
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:540-890-3027
Mailing Address - Street 1:15818 STEWARTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179
Mailing Address - Country:US
Mailing Address - Phone:540-890-3027
Mailing Address - Fax:540-890-5394
Practice Address - Street 1:15818 STEWARTSVILLE RD
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179
Practice Address - Country:US
Practice Address - Phone:540-890-3027
Practice Address - Fax:540-890-5394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201001662333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4815392OtherNABP
VA008512191Medicaid
VA4815392OtherNABP
008512191Medicare ID - Type Unspecified