Provider Demographics
NPI:1053416917
Name:JOHNSONS VILLAGE PHARMACY
Entity type:Organization
Organization Name:JOHNSONS VILLAGE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:716-753-3200
Mailing Address - Street 1:99 E CHAUTAUQUA ST
Mailing Address - Street 2:STE 3
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1017
Mailing Address - Country:US
Mailing Address - Phone:716-753-3200
Mailing Address - Fax:716-753-3206
Practice Address - Street 1:99 E CHAUTAUQUA ST
Practice Address - Street 2:STE 3
Practice Address - City:MAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:14757-1017
Practice Address - Country:US
Practice Address - Phone:716-753-3200
Practice Address - Fax:716-753-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0253173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02316558Medicaid
2064335OtherPK
NY02316558Medicaid