Healthcare Provider Details

I. General information

NPI: 1720164155
Provider Name (Legal Business Name): DOUGLAS HAROLD JOHNSON PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W 16TH AVE
TYNDALL SD
57066
US

IV. Provider business mailing address

41219 SD HIGHWAY 50
TYNDALL SD
57066-5934
US

V. Phone/Fax

Practice location:
  • Phone: 605-589-4418
  • Fax:
Mailing address:
  • Phone: 605-589-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3669
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: