Healthcare Provider Details

I. General information

NPI: 1306172507
Provider Name (Legal Business Name): SHANE P JOHNSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E JEFFERSON ST
SPRING GREEN WI
53588-8002
US

IV. Provider business mailing address

208 E JEFFERSON ST
SPRING GREEN WI
53588-8002
US

V. Phone/Fax

Practice location:
  • Phone: 608-588-2541
  • Fax:
Mailing address:
  • Phone: 608-588-2541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15782-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: