Provider Demographics
NPI:1972676328
Name:JOHNSON, DAVID WAYNE (RPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WAYNE
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 1:203 E SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-2139
Mailing Address - Country:US
Mailing Address - Phone:815-664-5050
Mailing Address - Fax:815-663-4069
Practice Address - Street 1:203 E SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-2139
Practice Address - Country:US
Practice Address - Phone:815-664-5050
Practice Address - Fax:815-663-4069
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362982894001Medicaid
IL1048730001Medicare NSC