Provider Demographics
NPI:1871136986
Name:JAY'S ROADHOUSE AND PHARMACY LLC
Entity type:Organization
Organization Name:JAY'S ROADHOUSE AND PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:970-291-8813
Mailing Address - Street 1:42225 DEER RD
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80487-9159
Mailing Address - Country:US
Mailing Address - Phone:970-871-4596
Mailing Address - Fax:
Practice Address - Street 1:840 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487-5005
Practice Address - Country:US
Practice Address - Phone:970-879-1114
Practice Address - Fax:970-879-5643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy