Healthcare Provider Details

I. General information

NPI: 1174927800
Provider Name (Legal Business Name): ELIZABETH JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 E PARKS HWY
WASILLA AK
99654-7349
US

IV. Provider business mailing address

1721 E PARKS HWY
WASILLA AK
99654-7349
US

V. Phone/Fax

Practice location:
  • Phone: 907-631-0300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2278
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: