Provider Demographics
NPI:1073062147
Name:JOHNSON, KARISSA MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:MARIE
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 1:160 N RESEARCH PL
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4458
Mailing Address - Country:US
Mailing Address - Phone:631-297-2011
Mailing Address - Fax:
Practice Address - Street 1:160 N RESEARCH PL
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4458
Practice Address - Country:US
Practice Address - Phone:631-297-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist