Provider Demographics
NPI:1477586642
Name:STEPHEN MICHAEL JOHNSON
Entity Type:Organization
Organization Name:STEPHEN MICHAEL JOHNSON
Other - Org Name:VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PIC
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:276-431-2299
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:DUFFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24244-0383
Mailing Address - Country:US
Mailing Address - Phone:276-431-2299
Mailing Address - Fax:276-431-2191
Practice Address - Street 1:443 DUFF PATT HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244-5191
Practice Address - Country:US
Practice Address - Phone:276-431-2299
Practice Address - Fax:276-431-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003487333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4832475OtherOTHER ID NUMBER
VA008514011Medicaid
VAVA8514011Medicaid
1209400001Medicare NSC