Provider Demographics
NPI:1720691124
Name:JOHNSON, SHALECE NICOLE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:SHALECE
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 BARDIC CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7600
Mailing Address - Country:US
Mailing Address - Phone:314-372-6950
Mailing Address - Fax:
Practice Address - Street 1:13992 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4517
Practice Address - Country:US
Practice Address - Phone:636-227-9228
Practice Address - Fax:636-227-9278
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020006539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist