Provider Demographics
NPI:1689032757
Name:JOHNSON AND ENTREKIN PHARMACY LLC
Entity Type:Organization
Organization Name:JOHNSON AND ENTREKIN PHARMACY LLC
Other - Org Name:JOHNSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-257-5400
Mailing Address - Street 1:205 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BOWDON
Mailing Address - State:GA
Mailing Address - Zip Code:30108-1108
Mailing Address - Country:US
Mailing Address - Phone:657-257-5400
Mailing Address - Fax:678-257-5403
Practice Address - Street 1:205 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BOWDON
Practice Address - State:GA
Practice Address - Zip Code:30108-1108
Practice Address - Country:US
Practice Address - Phone:678-257-5400
Practice Address - Fax:678-257-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010264333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003173146AMedicaid
2157968OtherPK
GA7569080001Medicare NSC