Provider Demographics
NPI:1053459230
Name:JOHNSON, STACEY (RPH)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 LIMESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-1159
Mailing Address - Country:US
Mailing Address - Phone:740-773-7822
Mailing Address - Fax:
Practice Address - Street 1:311 CALDWELL ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-3332
Practice Address - Country:US
Practice Address - Phone:740-775-6242
Practice Address - Fax:740-773-0218
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-18915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03-1-18915OtherOHIO PHARMACIST LICENSE