Provider Demographics
NPI:1740595701
Name:JOHNSON, LEROY (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:LEROY
Middle Name:
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 1:4097 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2819
Mailing Address - Country:US
Mailing Address - Phone:337-474-0434
Mailing Address - Fax:337-474-2778
Practice Address - Street 1:4097 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2819
Practice Address - Country:US
Practice Address - Phone:337-474-0434
Practice Address - Fax:337-474-2778
Is Sole Proprietor?:No
Enumeration Date:2010-08-15
Last Update Date:2010-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist