Provider Demographics
NPI:1881819605
Name:WILLIAM CARLYLE JOHNSON
Entity Type:Organization
Organization Name:WILLIAM CARLYLE JOHNSON
Other - Org Name:RIVERSIDE MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CARLYLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-536-1414
Mailing Address - Street 1:710 MADISON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3519
Mailing Address - Country:US
Mailing Address - Phone:931-536-1414
Mailing Address - Fax:931-684-6999
Practice Address - Street 1:710 MADISON ST
Practice Address - Street 2:SUITE C
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3519
Practice Address - Country:US
Practice Address - Phone:931-536-1414
Practice Address - Fax:931-684-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5884560001332BX2000X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455165Medicaid