Provider Demographics
NPI:1780777110
Name:JONESTOWN PHARMACY, INC
Entity type:Organization
Organization Name:JONESTOWN PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:VLANOS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-774-1445
Mailing Address - Street 1:300 JONESTOWN RD
Mailing Address - Street 2:STE 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:STE 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:2006-09-30
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC080413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703601Medicaid
2068997OtherPK
2068997OtherPK