Provider Demographics
NPI:1720606072
Name:JOHNSON, WILLIE TREMAINE JR (PHARMACY TECH)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:TREMAINE
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:PHARMACY TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 TUSCARAWAS ST W
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-5619
Mailing Address - Country:US
Mailing Address - Phone:330-478-8129
Mailing Address - Fax:
Practice Address - Street 1:3720 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-5619
Practice Address - Country:US
Practice Address - Phone:330-478-8129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician