Provider Demographics
NPI:1174876411
Name:JOHNSON, BARRY D (PHARMD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E RIVERVIEW EXPY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5483
Mailing Address - Country:US
Mailing Address - Phone:715-421-1779
Mailing Address - Fax:
Practice Address - Street 1:1100 E RIVERVIEW EXPY
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5483
Practice Address - Country:US
Practice Address - Phone:715-421-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15082-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist