Provider Demographics
NPI:1932110434
Name:BOB JOHNSONS PHARMACY INC
Entity Type:Organization
Organization Name:BOB JOHNSONS PHARMACY INC
Other - Org Name:BOB JOHNSONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-244-5984
Mailing Address - Street 1:1407 NW 85TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-4237
Mailing Address - Country:US
Mailing Address - Phone:206-782-5822
Mailing Address - Fax:206-781-0379
Practice Address - Street 1:1407 NW 85TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-4237
Practice Address - Country:US
Practice Address - Phone:206-782-5822
Practice Address - Fax:206-781-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000033053336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6030654Medicaid
2108490OtherPK