Healthcare Provider Details

I. General information

NPI: 1689032757
Provider Name (Legal Business Name): JOHNSON AND ENTREKIN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E COLLEGE ST
BOWDON GA
30108-1108
US

IV. Provider business mailing address

205 E COLLEGE ST
BOWDON GA
30108-1108
US

V. Phone/Fax

Practice location:
  • Phone: 678-257-5400
  • Fax: 678-257-5403
Mailing address:
  • Phone: 657-257-5400
  • Fax: 678-257-5403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE010264
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARTIN JOHNSON
Title or Position: PHARMACIST
Credential:
Phone: 678-257-5400