Provider Demographics
NPI:1053056390
Name:JOHNSON, CHARLES ANTHONY III
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WEBSTER ST APT 635
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4699
Mailing Address - Country:US
Mailing Address - Phone:614-787-0936
Mailing Address - Fax:
Practice Address - Street 1:2000 MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2807
Practice Address - Country:US
Practice Address - Phone:510-339-8535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist