Provider Demographics
NPI:1134499379
Name:JOHNSON, BURTON LEROY (RPH)
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:LEROY
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 1:1800 TIMBERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2842
Mailing Address - Country:US
Mailing Address - Phone:757-236-4260
Mailing Address - Fax:
Practice Address - Street 1:700 FREDERICK BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3314
Practice Address - Country:US
Practice Address - Phone:757-391-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009966183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist