Provider Demographics
NPI:1467577627
Name:JOHNSON, PAUL EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-0047
Mailing Address - Country:US
Mailing Address - Phone:315-926-5636
Mailing Address - Fax:315-926-0137
Practice Address - Street 1:3803 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NY
Practice Address - Zip Code:14505-0047
Practice Address - Country:US
Practice Address - Phone:315-926-5636
Practice Address - Fax:315-926-0137
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036101183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist