Provider Demographics
NPI:1083964761
Name:JOHNSON, PHILLIP RYAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:RYAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 E BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-3972
Mailing Address - Country:US
Mailing Address - Phone:214-883-2163
Mailing Address - Fax:214-242-4321
Practice Address - Street 1:1415 N ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-1616
Practice Address - Country:US
Practice Address - Phone:480-293-0052
Practice Address - Fax:480-293-0060
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist