Provider Demographics
NPI:1386654135
Name:VILLANOVA, JONATHAN ROBERT (R PH)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:VILLANOVA
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SHADYLAWN DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1443
Mailing Address - Country:US
Mailing Address - Phone:336-774-1235
Mailing Address - Fax:
Practice Address - Street 1:5030 PETERS CREEK PKWY
Practice Address - Street 2:MARLEY DRUG
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127
Practice Address - Country:US
Practice Address - Phone:336-771-7672
Practice Address - Fax:336-771-9921
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist