Provider Demographics
NPI:1902022981
Name:JOHNSON, TERRY DAVID (RPH)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 US HIGHWAY 51 AND 138
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1907
Mailing Address - Country:US
Mailing Address - Phone:608-873-7612
Mailing Address - Fax:608-873-7894
Practice Address - Street 1:1705 US HIGHWAY 51 AND 138
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1907
Practice Address - Country:US
Practice Address - Phone:608-873-7612
Practice Address - Fax:608-873-7894
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-035717183500000X
WI14896-040183500000X
IA16566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist