Provider Demographics
NPI:1336246271
Name:JOHNSON DRUG WILLIAMSBURG INC.
Entity Type:Organization
Organization Name:JOHNSON DRUG WILLIAMSBURG INC.
Other - Org Name:JOHNSON DRUG WILLIAMSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-347-5185
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28541-0250
Mailing Address - Country:US
Mailing Address - Phone:910-938-0582
Mailing Address - Fax:910-938-0239
Practice Address - Street 1:2200 GUM BRANCH RD
Practice Address - Street 2:STE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4574
Practice Address - Country:US
Practice Address - Phone:910-938-0582
Practice Address - Fax:910-938-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC088663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2072370OtherPK
NC0675595Medicaid