MEDICARE: DR. JACOB CHARLES 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	45553	TN

General Provider Information

NPI Number	:	1306517743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB CHARLES JOHNSON PHARMD

Provider Business Mailing Address
First Line	:	145 RIVERWALK PL
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38103-0846
Country	:	US
Telephone Number	:	502-974-5417
Fax Number	:

Provider Business Practice Location Address
First Line	:	3502 PARK AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38111-5622
Country	:	US
Telephone Number	:	901-324-1050
Fax Number	:

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

Provider Enumeration Date	:	09/24/2021
Last Update Date	:	09/24/2021

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