Provider Demographics
NPI:1164653036
Name:JOHNSON, KENNETH R (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
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 1:2393 SILVER CIR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1741
Mailing Address - Country:US
Mailing Address - Phone:248-673-7014
Mailing Address - Fax:
Practice Address - Street 1:KNIGHT SERVICE COMPANY
Practice Address - Street 2:2520 INDUSTRIAL ROW DRIVE
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-540-8066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist