Provider Demographics
NPI:1164706925
Name:JOHNSON, ANGELA B
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2505
Mailing Address - Country:US
Mailing Address - Phone:314-770-2479
Mailing Address - Fax:314-770-1757
Practice Address - Street 1:12345 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2505
Practice Address - Country:US
Practice Address - Phone:314-770-2479
Practice Address - Fax:314-770-1757
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007022162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist