Provider Demographics
NPI:1790834968
Name:JONICO INC
Entity Type:Organization
Organization Name:JONICO INC
Other - Org Name:YOUGH VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-445-6089
Mailing Address - Street 1:511 WILLIAMS ST
Mailing Address - Street 2:SUITE #2
Mailing Address - City:CONFLUENCE
Mailing Address - State:PA
Mailing Address - Zip Code:15424-1048
Mailing Address - Country:US
Mailing Address - Phone:814-395-5300
Mailing Address - Fax:
Practice Address - Street 1:511 WILLIAMS ST
Practice Address - Street 2:SUITE #2
Practice Address - City:CONFLUENCE
Practice Address - State:PA
Practice Address - Zip Code:15424-1048
Practice Address - Country:US
Practice Address - Phone:814-395-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410073L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007513050009Medicaid
PA1007513050009Medicaid