=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902370364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANASTASIA MARIE JOHNSON PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2019
-----------------------------------------------------
Last Update Date | 01/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11305 W LINCOLN HWY
-----------------------------------------------------
City | MOKENA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60448-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-277-0510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16359 STONEY BROOK DR
-----------------------------------------------------
City | LEMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60439-4775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-518-5064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051299427
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------