Provider Demographics
NPI:1114406899
Name:JOHNSON, LOUIS LAVERNE (RPH)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:LAVERNE
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 1:1500 ANNA SPARKS WAY
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-4170
Mailing Address - Country:US
Mailing Address - Phone:808-346-9356
Mailing Address - Fax:
Practice Address - Street 1:1500 ANNA SPARKS WAY
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-4170
Practice Address - Country:US
Practice Address - Phone:707-839-0140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39146183500000X, 1835P0018X
CA3946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39146OtherPHARMACIST