Healthcare Provider Details

I. General information

NPI: 1013610641
Provider Name (Legal Business Name): CHET JOHNSON DRUG CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 KELLER AVE N
AMERY WI
54001-1036
US

IV. Provider business mailing address

PO BOX 17
AMERY WI
54001-0017
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-8121
  • Fax: 715-268-4733
Mailing address:
  • Phone: 715-268-8121
  • Fax: 715-268-4733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: MATTHEW JOHNSON
Title or Position: MANAGING MEMBER
Credential:
Phone: 715-268-8121