Provider Demographics
NPI:1083986525
Name:JOHNSON, RAY (BS)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S VISITING EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:NIOBRARA
Mailing Address - State:NE
Mailing Address - Zip Code:68760-7201
Mailing Address - Country:US
Mailing Address - Phone:402-857-2300
Mailing Address - Fax:402-857-2416
Practice Address - Street 1:110 S VISITING EAGLE ST
Practice Address - Street 2:
Practice Address - City:NIOBRARA
Practice Address - State:NE
Practice Address - Zip Code:68760-7201
Practice Address - Country:US
Practice Address - Phone:402-857-2300
Practice Address - Fax:402-857-2416
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR4204183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist