Provider Demographics
NPI:1689913998
Name:JONESTOWN PHARMACY
Entity Type:Organization
Organization Name:JONESTOWN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:VLAHOS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-774-1445
Mailing Address - Street 1:300 JONESTOWN RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4621
Mailing Address - Country:US
Mailing Address - Phone:336-774-1445
Mailing Address - Fax:336-774-1986
Practice Address - Street 1:300 JONESTOWN RD
Practice Address - Street 2:SUITE 5
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4621
Practice Address - Country:US
Practice Address - Phone:336-774-1445
Practice Address - Fax:336-774-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0347048Medicaid