Provider Demographics
NPI:1093318727
Name:JOHNSON, PHILLIP A (RPH)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:511 CRUMBAUGH RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9764
Mailing Address - Country:US
Mailing Address - Phone:859-361-0363
Mailing Address - Fax:502-863-2976
Practice Address - Street 1:705 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1164
Practice Address - Country:US
Practice Address - Phone:502-863-9823
Practice Address - Fax:502-863-2976
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist