Provider Demographics
NPI:1679169866
Name:JOHNSON, DEATRA L (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEATRA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11502 TORI LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8833
Mailing Address - Country:US
Mailing Address - Phone:904-502-2851
Mailing Address - Fax:
Practice Address - Street 1:6005 SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2139
Practice Address - Country:US
Practice Address - Phone:904-733-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist