Provider Demographics
NPI:1194844126
Name:JOHNSON, CAROL M (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S BLISS AVE
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:TX
Mailing Address - Zip Code:79029-4434
Mailing Address - Country:US
Mailing Address - Phone:806-935-2333
Mailing Address - Fax:
Practice Address - Street 1:601 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:TX
Practice Address - Zip Code:79029-4434
Practice Address - Country:US
Practice Address - Phone:806-935-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16435183500000X
TX024723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16435OtherPERSONAL PHARMACY LICENSE
TX02472OtherPHARMACY STORE NUMBER
TX143922Medicaid
TX20002809OtherDPS
TX20002809OtherDPS