MEDICARE: MR. SHANE P JOHNSON PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	15782-040	WI

General Provider Information

NPI Number	:	1306172507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHANE P JOHNSON PHARMD

Provider Business Mailing Address
First Line	:	208 E JEFFERSON ST
Second Line	:
City	:	SPRING GREEN
State	:	WI
Zip	:	53588-8002
Country	:	US
Telephone Number	:	608-588-2541
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 E JEFFERSON ST
Second Line	:
City	:	SPRING GREEN
State	:	WI
Zip	:	53588-8002
Country	:	US
Telephone Number	:	608-588-2541
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2009
Last Update Date	:	10/22/2009

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