=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417874066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALLISA JOHNSON CPHT-ADV
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2026
-----------------------------------------------------
Last Update Date | 07/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 S MAIN ST
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-3046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-883-6245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 517 ELM ST # 194
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83871-0077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-596-5223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | CT1222
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------