Provider Demographics
NPI:1215060793
Name:JOHNSON, WILLIAM CARLYLE (DPH)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CARLYLE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3519
Mailing Address - Country:US
Mailing Address - Phone:931-684-1081
Mailing Address - Fax:931-684-2668
Practice Address - Street 1:710 MADISON ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3519
Practice Address - Country:US
Practice Address - Phone:931-684-1081
Practice Address - Fax:931-684-2668
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist