Provider Demographics
NPI:1407173636
Name:JOHNSON, KELLEY RAY (RPH)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:RAY
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 1:429 E MAIN ST
Mailing Address - Street 2:INGLES PHARMACY #253
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-1574
Mailing Address - Country:US
Mailing Address - Phone:864-843-9326
Mailing Address - Fax:864-843-9352
Practice Address - Street 1:429 E MAIN ST
Practice Address - Street 2:INGLES PHARMACY #253
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1574
Practice Address - Country:US
Practice Address - Phone:864-843-9326
Practice Address - Fax:864-843-9352
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist