Provider Demographics
NPI:1043976301
Name:JOHNSON, ANDREA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
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:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:CASTLEWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24224-0545
Mailing Address - Country:US
Mailing Address - Phone:276-608-8593
Mailing Address - Fax:
Practice Address - Street 1:16410 WISE STREET
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:VA
Practice Address - Zip Code:24283
Practice Address - Country:US
Practice Address - Phone:276-762-4009
Practice Address - Fax:276-762-8113
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202012606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist