Provider Demographics
NPI:1578618310
Name:JOHNSON, THOMAS J (PD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6124 HEBER SPRINGS RD WEST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:AR
Mailing Address - Zip Code:72131-0164
Mailing Address - Country:US
Mailing Address - Phone:501-589-2890
Mailing Address - Fax:501-589-3780
Practice Address - Street 1:6124 HEBER SPRINGS RD WEST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:AR
Practice Address - Zip Code:72131-0164
Practice Address - Country:US
Practice Address - Phone:501-589-2890
Practice Address - Fax:501-589-3780
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD05864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist