Provider Demographics
NPI:1659480838
Name:JOHNSON, WALLACE ALLEN JR
Entity type:Individual
Prefix:MISS
First Name:WALLACE
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:JR
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 1:933 OLD ROCKFORD ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-5356
Mailing Address - Country:US
Mailing Address - Phone:336-789-0424
Mailing Address - Fax:336-789-0157
Practice Address - Street 1:933 OLD ROCKFORD ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5356
Practice Address - Country:US
Practice Address - Phone:336-789-0424
Practice Address - Fax:336-789-0157
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist