Provider Demographics
NPI:1447861687
Name:EASTERLING, JOHNATHAN GRADY (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:GRADY
Last Name:EASTERLING
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 1:1028 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1532
Mailing Address - Country:US
Mailing Address - Phone:608-375-4466
Mailing Address - Fax:
Practice Address - Street 1:1028 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1532
Practice Address - Country:US
Practice Address - Phone:608-375-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20372-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist