Provider Demographics
NPI:1962057802
Name:JOHNSON, JERRY MICHAEL (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S AVENUE D
Mailing Address - Street 2:
Mailing Address - City:BURKBURNETT
Mailing Address - State:TX
Mailing Address - Zip Code:76354-3541
Mailing Address - Country:US
Mailing Address - Phone:940-569-3319
Mailing Address - Fax:940-569-5359
Practice Address - Street 1:311 S AVENUE D
Practice Address - Street 2:
Practice Address - City:BURKBURNETT
Practice Address - State:TX
Practice Address - Zip Code:76354-3541
Practice Address - Country:US
Practice Address - Phone:940-569-3319
Practice Address - Fax:940-569-5359
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist