Provider Demographics
NPI:1124397567
Name:CALDWELL, JOHNNY M (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:M
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:JOHNNY
Other - Middle Name:M
Other - Last Name:CALDWELL
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1790 W GOV ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2411
Mailing Address - Country:US
Mailing Address - Phone:601-825-3473
Mailing Address - Fax:601-825-5909
Practice Address - Street 1:1790 W GOV ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2411
Practice Address - Country:US
Practice Address - Phone:601-825-3473
Practice Address - Fax:601-825-5909
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-5140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist