Provider Demographics
NPI:1164778619
Name:JOHNSON, MARK ANTHONY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 EAST REZANOF DRIVE
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615
Mailing Address - Country:US
Mailing Address - Phone:907-486-9860
Mailing Address - Fax:907-486-9895
Practice Address - Street 1:3449 REZANOF DRIVE
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-486-9860
Practice Address - Fax:907-486-9895
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist