Provider Demographics
NPI:1477958544
Name:JOHNSON, TOMINIQUE LATRICE
Entity type:Individual
Prefix:DR
First Name:TOMINIQUE
Middle Name:LATRICE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-4339
Mailing Address - Country:US
Mailing Address - Phone:773-542-1232
Mailing Address - Fax:
Practice Address - Street 1:3401 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-4339
Practice Address - Country:US
Practice Address - Phone:773-542-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.298046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist