Provider Demographics
NPI:1962727677
Name:JOHNSON, CARY DALE (RPH)
Entity type:Individual
Prefix:MR
First Name:CARY
Middle Name:DALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10402 AL HIGHWAY 168
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-1951
Mailing Address - Country:US
Mailing Address - Phone:256-593-6546
Mailing Address - Fax:256-593-3137
Practice Address - Street 1:10402 AL HIGHWAY 168
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-1951
Practice Address - Country:US
Practice Address - Phone:256-593-6546
Practice Address - Fax:256-593-3137
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100001098Medicaid
LA1299553Medicaid
AL026718001Medicare PIN
LA1299553Medicaid