Provider Demographics
NPI:1629149323
Name:JOHNSON, JEROME P (BS)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:218 E COLLEGE AVE
Mailing Address - City:HOWARD
Mailing Address - State:SD
Mailing Address - Zip Code:57349-0481
Mailing Address - Country:US
Mailing Address - Phone:605-772-4286
Mailing Address - Fax:
Practice Address - Street 1:108 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOWARD
Practice Address - State:SD
Practice Address - Zip Code:57349-0250
Practice Address - Country:US
Practice Address - Phone:605-772-5581
Practice Address - Fax:605-772-5571
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD4073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist