Provider Demographics
NPI:1326504085
Name:JOHNSON, AVENELLE K (RPH)
Entity Type:Individual
Prefix:
First Name:AVENELLE
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4223
Mailing Address - Country:US
Mailing Address - Phone:607-297-8702
Mailing Address - Fax:
Practice Address - Street 1:1179 VESTAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1606
Practice Address - Country:US
Practice Address - Phone:607-723-7584
Practice Address - Fax:607-773-0936
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist