Provider Demographics
NPI:1063689537
Name:JOHNSON, KELLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1775 DEMPSTER ST
Mailing Address - Street 2:DEPARTMENT OF PHARMACY
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1143
Mailing Address - Country:US
Mailing Address - Phone:847-723-5890
Mailing Address - Fax:
Practice Address - Street 1:1775 DEMPSTER ST
Practice Address - Street 2:DEPARTMENT OF PHARMACY
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1143
Practice Address - Country:US
Practice Address - Phone:847-723-5890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0512903091835P0018X
GARPH0204091835P0018X
VA02022063141835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist