Provider Demographics
NPI:1437636685
Name:JOHNSON, ROYAL WILLIAM
Entity Type:Individual
Prefix:
First Name:ROYAL
Middle Name:WILLIAM
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 1:911 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-8608
Mailing Address - Country:US
Mailing Address - Phone:208-788-6709
Mailing Address - Fax:
Practice Address - Street 1:911 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8608
Practice Address - Country:US
Practice Address - Phone:208-788-6709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist