Provider Demographics
NPI:1780964437
Name:JOHNSON, ROY C
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:C
Last Name:JOHNSON
Suffix:
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 1:897 SAXON BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8204
Mailing Address - Country:US
Mailing Address - Phone:386-775-5336
Mailing Address - Fax:386-775-8956
Practice Address - Street 1:897 SAXON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8204
Practice Address - Country:US
Practice Address - Phone:386-775-5336
Practice Address - Fax:386-775-8956
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS14000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist