Provider Demographics
NPI:1760766554
Name:JOHNSON, ADLAI (DPH)
Entity Type:Individual
Prefix:
First Name:ADLAI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 ELVIS PRESLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7121
Mailing Address - Country:US
Mailing Address - Phone:901-346-4658
Mailing Address - Fax:901-346-1363
Practice Address - Street 1:4653 ELVIS PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7121
Practice Address - Country:US
Practice Address - Phone:901-346-4658
Practice Address - Fax:901-346-1363
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist