Provider Demographics
NPI:1942081385
Name:WALKER, JOHNNY MARK
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:MARK
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 EAGLE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5462
Mailing Address - Country:US
Mailing Address - Phone:256-322-1056
Mailing Address - Fax:
Practice Address - Street 1:1351 W FORT WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2775
Practice Address - Country:US
Practice Address - Phone:256-245-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist