Provider Demographics
NPI:1225035272
Name:JOHNSON, JON DAVID (BS MLS MBA PD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS MLS MBA PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1467
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-1467
Mailing Address - Country:US
Mailing Address - Phone:301-705-6049
Mailing Address - Fax:301-609-7816
Practice Address - Street 1:9050 POORHOUSE RD
Practice Address - Street 2:
Practice Address - City:PORT TOBACCO
Practice Address - State:MD
Practice Address - Zip Code:20677-3027
Practice Address - Country:US
Practice Address - Phone:301-934-3020
Practice Address - Fax:301-609-7816
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD066861835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric