Provider Demographics
NPI:1265889075
Name:JOHNSON, NIKOLAI (PHARMD)
Entity type:Individual
Prefix:
First Name:NIKOLAI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9424 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1935
Mailing Address - Country:US
Mailing Address - Phone:708-857-8940
Mailing Address - Fax:708-857-8128
Practice Address - Street 1:9424 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1935
Practice Address - Country:US
Practice Address - Phone:708-857-8940
Practice Address - Fax:708-857-8128
Is Sole Proprietor?:No
Enumeration Date:2016-05-22
Last Update Date:2016-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist