Provider Demographics
NPI:1679106090
Name:WILLIAMS, JOHN EDWARD JR
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:WILLIAMS
Suffix:JR
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 1:19107 BLACK MAPLE WAY
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1675
Mailing Address - Country:US
Mailing Address - Phone:240-469-5355
Mailing Address - Fax:
Practice Address - Street 1:18726 N POINTE DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2418
Practice Address - Country:US
Practice Address - Phone:240-420-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD183500000XMedicaid