Provider Demographics
NPI:1306145834
Name:JOHNSON, LISA WOODALL (LISA JOHNSON)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:WOODALL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LISA JOHNSON
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:251 TALLY HO DR
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-8452
Mailing Address - Country:US
Mailing Address - Phone:919-965-9563
Mailing Address - Fax:
Practice Address - Street 1:11360 US HWY 70 WEST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520
Practice Address - Country:US
Practice Address - Phone:919-553-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist