Healthcare Provider Details

I. General information

NPI: 1649577214
Provider Name (Legal Business Name): ELYSICA L JOHNSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 HIGHWAY 305 N
OLIVE BRANCH MS
38654-3602
US

IV. Provider business mailing address

3324 JEFF BROWNING BLVD
OLIVE BRANCH MS
38654-7303
US

V. Phone/Fax

Practice location:
  • Phone: 662-890-3548
  • Fax:
Mailing address:
  • Phone: 901-604-0938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21793
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberT-102580
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: