Healthcare Provider Details

I. General information

NPI: 1053416917
Provider Name (Legal Business Name): JOHNSONS VILLAGE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 E CHAUTAUQUA ST STE 3
MAYVILLE NY
14757-1017
US

IV. Provider business mailing address

99 E CHAUTAUQUA ST STE 3
MAYVILLE NY
14757-1017
US

V. Phone/Fax

Practice location:
  • Phone: 716-753-3200
  • Fax: 716-753-3206
Mailing address:
  • Phone: 716-753-3200
  • Fax: 716-753-3206

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 Number025317
License Number StateNY

VIII. Authorized Official

Name: LESLIE JOHNSON
Title or Position: PHARMACIST AND OWNER
Credential: BS PHARMACY
Phone: 716-753-3200