Provider Demographics
NPI:1184162844
Name:JOLLY'S DRUG STORE LLC
Entity type:Organization
Organization Name:JOLLY'S DRUG STORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-358-9608
Mailing Address - Street 1:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:CALIENTE
Mailing Address - State:NV
Mailing Address - Zip Code:89008-1011
Mailing Address - Country:US
Mailing Address - Phone:775-725-3515
Mailing Address - Fax:775-725-3518
Practice Address - Street 1:414 BROADWAY
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:NV
Practice Address - Zip Code:89001
Practice Address - Country:US
Practice Address - Phone:775-725-3515
Practice Address - Fax:775-725-3518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH03674333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy