Provider Demographics
NPI:1184711087
Name:CHET JOHNSON DRUGS, INC.
Entity type:Organization
Organization Name:CHET JOHNSON DRUGS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-268-8121
Mailing Address - Street 1:PO BOX 17
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54000-0017
Mailing Address - Country:US
Mailing Address - Phone:715-268-8121
Mailing Address - Fax:715-268-4733
Practice Address - Street 1:204 KELLER AVE N
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1036
Practice Address - Country:US
Practice Address - Phone:715-268-8121
Practice Address - Fax:715-268-4733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43690423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0490020001OtherPTAN
WI33100200Medicaid