Provider Demographics
NPI:1356688121
Name:JOHNSON, DANE
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:JOHNSON
Suffix:
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 1:1339 W PALMETTO PARK RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-3303
Mailing Address - Country:US
Mailing Address - Phone:561-362-5311
Mailing Address - Fax:561-447-1170
Practice Address - Street 1:1339 W PALMETTO PARK RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-3303
Practice Address - Country:US
Practice Address - Phone:561-362-5311
Practice Address - Fax:561-447-1170
Is Sole Proprietor?:No
Enumeration Date:2013-01-13
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS47808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist