MEDICARE: MARY GRACE 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	SC12803	SC

General Provider Information

NPI Number	:	1538453691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY GRACE JOHNSON PHARMD

Provider Business Mailing Address
First Line	:	134 HARBISON BLVD
Second Line	:	T1199
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2204
Country	:	US
Telephone Number	:	803-407-0328
Fax Number	:	803-407-0328

Provider Business Practice Location Address
First Line	:	134 HARBISON BLVD
Second Line	:	T1199
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2204
Country	:	US
Telephone Number	:	803-407-0328
Fax Number	:	803-407-0328

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

Provider Enumeration Date	:	06/07/2011
Last Update Date	:	06/07/2011

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