Provider Demographics
NPI:1710631585
Name:DEEL, JOHNATHAN WESLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:WESLEY
Last Name:DEEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:VANSANT
Mailing Address - State:VA
Mailing Address - Zip Code:24656-8408
Mailing Address - Country:US
Mailing Address - Phone:276-935-6455
Mailing Address - Fax:276-935-2981
Practice Address - Street 1:1503 SLATE CREEK RD
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6974
Practice Address - Country:US
Practice Address - Phone:276-935-6455
Practice Address - Fax:276-935-2981
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist