Provider Demographics
NPI:1780804120
Name:JOHNSON, THADRIAN MARQUIS (RPH)
Entity type:Individual
Prefix:
First Name:THADRIAN
Middle Name:MARQUIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:HAHNVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70057-0012
Mailing Address - Country:US
Mailing Address - Phone:985-783-6316
Mailing Address - Fax:985-783-6316
Practice Address - Street 1:12125 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-3000
Practice Address - Country:US
Practice Address - Phone:985-783-6316
Practice Address - Fax:985-783-6316
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0013452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist