=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326385220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHNSON PHARMACY OF MERRILL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2013
-----------------------------------------------------
Last Update Date | 06/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 E MAIN ST
-----------------------------------------------------
City | MERRILL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54452-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-539-2772
-----------------------------------------------------
Fax | 715-539-0757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 E MAIN ST
-----------------------------------------------------
City | MERRILL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54452-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-539-2772
-----------------------------------------------------
Fax | 715-539-0757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | MR. ROBERT GENE JOHNSON
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 715-539-2772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 9185-42
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------