Provider Demographics
NPI:1720164155
Name:JOHNSON, DOUGLAS HAROLD (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:HAROLD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41219 SD HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-5934
Mailing Address - Country:US
Mailing Address - Phone:605-589-3725
Mailing Address - Fax:
Practice Address - Street 1:410 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:TYNDALL
Practice Address - State:SD
Practice Address - Zip Code:57066
Practice Address - Country:US
Practice Address - Phone:605-589-4418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist