Provider Demographics
NPI:1225647258
Name:JOHNSON, JEFFREY SLADE
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SLADE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4753 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7307
Mailing Address - Country:US
Mailing Address - Phone:678-639-4500
Mailing Address - Fax:678-639-4511
Practice Address - Street 1:4753 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7307
Practice Address - Country:US
Practice Address - Phone:678-639-4500
Practice Address - Fax:678-639-4511
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0161211835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist