Healthcare Provider Details

I. General information

NPI: 1164529004
Provider Name (Legal Business Name): JOHNSON WESTPARK DRUGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 RICHLANDS HWY
JACKSONVILLE NC
28540-2926
US

IV. Provider business mailing address

PO BOX 250
JACKSONVILLE NC
28541-0250
US

V. Phone/Fax

Practice location:
  • Phone: 910-455-9222
  • Fax: 910-938-2221
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number08864
License Number StateNC

VIII. Authorized Official

Name: ANTHONY MEDLIN
Title or Position: PRESIDENT
Credential:
Phone: 910-347-5185