Provider Demographics
NPI:1366042855
Name:JOHNSON, KYLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
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 1:161 N WALMART DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-1960
Mailing Address - Country:US
Mailing Address - Phone:870-741-2327
Mailing Address - Fax:870-741-4115
Practice Address - Street 1:161 N WALMART DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-1960
Practice Address - Country:US
Practice Address - Phone:870-741-2327
Practice Address - Fax:870-741-4115
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126405OtherNABP